To identify enablers and barriers for scaling up non-communicable disease (NCD) interventions across diverse global contexts and to map these factors to the WHO’s health system building blocks.

A multi-method qualitative study applying the Consolidated Framework for Implementation Research to analyse data from multiple projects nearing or completing scale-up.

Global Alliance for Chronic Diseases-funded implementation research projects conducted across 18 low- and middle-income countries and high-income settings.

Data was derived from documents (n=77) including peer-reviewed publications, policy briefs, and reports and interviews with stakeholders (n=18) (eg, principal investigators, medical professionals, public health workers).

Various context-specific interventions targeting sustainable scale-up of NCD (eg, diabetes, hypertension, cardiovascular disease) interventions at the community, primary care or policy levels.

The primary outcome was identifying contextual enablers and barriers to intervention scale-up. Secondary outcomes included exploring how these factors aligned with health system building blocks (eg, leadership/governance, healthcare workforce).

Twenty enablers (eg, intervention adaptability, strong stakeholder engagement, local empowerment) and 25 barriers (eg, resource limitations, intervention complexity, stakeholder burnout) were identified. Contextual alignment, supportive governance and capacity building were critical for sustainability, while cultural misalignment and socio-political instability frequently hampered scaling efforts.

Tailoring interventions to local health systems, ensuring stakeholder co-ownership and incorporating strategies to mitigate stakeholder burn-out are essential to achieving sustainable, scalable NCD solutions. Future research should focus on integrating systematic cultural adaptation, sustainable financing and workforce capacity building into scale-up planning.

To conduct a systematic review and narrative synthesis to identify barriers, facilitators and pre-existing interventions and describe the current status of initiatives/interventions aimed at improving access to quality trauma healthcare after injury in Pakistan.

Systematic review and narrative synthesis

MEDLINE (Ovid), Embase (Ovid), Web of Science (Clarivate Analytics), Cochrane (Wiley), Scopus and ProQuest, as well as grey literature.

Full-text peer-reviewed publications, including cross-sectional studies, cohort studies, case-control studies, randomised controlled trials and qualitative studies published in English from January 2013 to December 2023.

Two independent reviewers used a standardised tool to extract data variables to Excel. The quality of the included studies was evaluated using the CASP checklist. The barriers, facilitators and pre-existing interventions were mapped using the four delays framework, the Institute of Medicine (IOM) quality domains and the WHO health systems building blocks. The data were synthesised narratively to improve access to quality trauma care in Pakistan. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines.

The review included 20 studies. 19 studies reported 58 barriers to access to quality care. Six studies reported 20 facilitators, and eight studies described initiatives or interventions aimed at improving access to quality trauma healthcare after injury. According to the four delays framework, the receiving care stage of access to care was primarily studied in 16 studies, which identified 37 barriers and 13 facilitators across 5 studies. Regarding the quality of care according to IOM domains, the effectiveness of quality trauma care after an injury was studied in 15 studies, which identified 19 barriers and 10 facilitators across four studies. According to the WHO health system building blocks, most studies (n=15) described challenges in healthcare service delivery, with these 15 studies identifying 23 barriers and 3 studies identifying 4 facilitators.

Our findings highlighted the scarcity of available literature, identified barriers and facilitators and pre-existing interventions, which informed the need to develop feasible, sustainable and contextually relevant interventions to improve access to quality trauma care after injury in Pakistan.

CRD42024545786

Neurodegenerative disorders (NDDs) represent an unprecedented public health burden. These disorders are clinically heterogeneous and therapeutically challenging, but advances in discovery science and trial methodology offer hope for translation to new treatments. Against this background, there is an urgent unmet need for biomarkers to aid with early and accurate diagnosis, prognosis and monitoring throughout the care pathway and in clinical trials.

Investigations routinely used in clinical care and trials are often invasive, expensive, time-consuming, subjective and ordinal. Speech data represent a potentially scalable, non-invasive, objective and quantifiable digital biomarker that can be acquired remotely and cost-efficiently using mobile devices, and analysed using state-of-the-art speech signal processing and machine learning approaches. This prospective case–control observational study of multiple NDDs aims to deliver a deeply clinically phenotyped longitudinal speech dataset to facilitate development and evaluation of speech biomarkers.

People living with dementia, motor neuron disease, multiple sclerosis and Parkinson’s disease are eligible to participate. Healthy individuals (including relatives or carers of participants with neurological disease) are also eligible to participate as controls. Participants complete a study app with standardised speech recording tasks (including reading, free speech, picture description and verbal fluency tasks) and patient-reported outcome measures of quality of life and mood (EuroQol-5 Dimension-5 Level, Patient Health Questionnaire 2) every 2 months at home or in clinic. Participants also complete disease severity scales, cognitive screening tests and provide optional samples for blood-based biomarkers at baseline and then 6-monthly. Follow-up is scheduled for up to 24 months. Initially, 30 participants will be recruited to each group. Speech recordings and contemporaneous clinical data will be used to create a dataset for development and evaluation of novel speech-based diagnosis and monitoring algorithms.

Digital App for Speech and Health Monitoring Study was approved by the South Central—Hampshire B Ethics Committee (REC ref. 24/SC/0067), NHS Lothian (R&D ref. 2024/0034) and NHS Forth Valley (R&D ref. FV1494). Results of the study will be submitted for publication in peer-reviewed journals and conferences. Data from the study will be shared with other researchers and used to facilitate speech processing challenges for neurological disorders. Regular updates will be provided on the Anne Rowling Regenerative Neurology Clinic web page and social media platforms.

ClinicalTrials.gov NCT06450418 (pre-results).

Three-quarters of mental health problems start before the age of 25. However, young people are the least likely to receive mental healthcare. Some young people (such as those from ethnic minorities) are even less likely to receive mental healthcare than others. Long-term impacts of mental health problems include poorer physical health, relationships, education and employment. We aim to elicit the views, experiences and needs of diverse young people (aged 16–24 years), to better understand (1) their experiences of under-representation, mental health and coping, (2) mechanisms that shape mental health trajectories and (3) how online arts and culture might be made engaging and useful for young people’s mental health. We also aim to do this with autistic young people.

Narrative inquiry will be employed as a tool for gathering young people’s perspectives for an iterative analysis. The narrative method proposes that critical insights and knowledge are distributed across social systems and can be discovered in personal stories and that knowledge can be relayed, stored and retrieved through these stories. Data will be transcribed and explored using a combination of thematic and intersectional analysis. Young people will be core members of the research team, shape the research and be involved in the coding of data and interpretation of the findings.

This study (IRAS project ID 340259) has received ethical approval from the HRA and Health and Care Research Wales (REC reference 24/SC/0083). The outputs will identify touch points and refine the logic model of how online arts and culture might support the mental health of those from under-represented backgrounds. We will share knowledge with young people, policy makers, health professionals, carers, teachers, social workers and people who work in arts and culture. We will produce research papers, blogs, newsletters, webinars, videos and podcasts.

With the rapid increase in the number of older adults living with chronic diseases and disabilities, there is a growing need to prepare nurses with positive attitudes and a willingness to work with older adults. This study aims to examine attitudes towards and willingness to work with older adults among nurses.

A cross-sectional survey was conducted among a purposive sample of 267 nurses at the University Hospital of Kotelawala Defence University, Sri Lanka. Participants completed a self-administered questionnaire consisting of socio-demographic variables, Kogan’s Attitudes Toward Old People Scale and questions related to willingness to work with older adults. Descriptive statistics and linear and logistic regression analyses were used in data analysis.

The majority were female nurses (71.9%, n=192) and held slightly negative (58%, n=155) or slightly positive (41.9%, n=122) attitudes towards working with older adults. Only 35.2% (n=94) were willing to work with older adults in this study. A male nurse (beta coefficient (β)=4.644, CI 2.392 to 6.896, p

Most nurses express slightly negative to positive attitudes and have little interest in working with older adults. Various socio-demographic factors have an impact on attitudes towards and willingness to work with older adults. Since nurses play a significant role in providing care for older adults, the development of positive attitudes is essential, and interventions and strategies are crucial to increasing their willingness to work with older adults.

The study sought to understand the characteristics of community deaths due to cholera in Zambia. We sought to examine the drivers of mortality from cholera among communities in Zambia’s 2023–2024 outbreak.

This is a descriptive study of the characteristics of community deaths due to cholera in three provinces in Zambia. Routine surveillance data collected between 14 October 2023 and 16 April 2024, comprising a national line list of cholera deaths, were used for this study.

178 participants were included in the study and completed it. All community deaths on the line list were eligible for inclusion. This comprised: deceased individuals whose death was associated with cholera or who met the national cholera case definition (suspected or confirmed); death occurring in the community, en route or on arrival to a health facility prior to admission; and death must have occurred between 14 October 2023 and 16 April 2024. Deceased individuals whose family members could not be traced or did not consent to participate in the interview were excluded.

The primary outcome was identifying characteristics of cholera-related community deaths. There were no secondary outcomes measured.

Among 178 community deaths due to cholera, the majority were males (61.8%), with the highest mortality in adults aged 35–49 years (22.5%). Over half of the deaths occurred on arrival at healthcare facilities due to delays influenced by socioeconomic barriers. Comorbidities such as HIV/AIDS and hypertension were present in 23% of cases.

The study found that males, death on arrival at healthcare facilities, delays in seeking healthcare and comorbidities such as HIV/AIDS and hypertension were more frequently observed among those who died due to cholera in the community. These findings highlight the need for enhanced early care-seeking behaviours, improved access to timely treatment and targeted interventions for individuals with comorbidities to potentially reduce cholera mortality.

Hospital administrators (HAs) aim to strike a balance between providing efficient and compassionate treatment. Health informatics and service management abilities are two areas that are evolving alongside digital health. This study outlines the health information technology (IT) competencies necessary for sustainability in the healthcare industry and looks at the competencies needed for HAs to manage everyday responsibilities.

Grounded theory is used in this qualitative study and reported based on the Standards for Reporting Qualitative Research guidelines. The participants were HAs who worked in different healthcare fields and held MBAs from the same private university. Respondents were selected through purposeful sampling, and consent was obtained before conducting telephone conversations. Data were gathered until the point of theoretical saturation. Every theme was outlined in a thematic framework.

Healthcare administrators gain knowledge about using applications and technology through the service. A hospital setting is a good place for healthcare administrators to begin their careers to fully understand the intricacies of the field. The key findings of the study indicate that HAs recognised policies and procedures as important areas of competency that required focused attention. HAs are increasingly relying on mid- to advanced-level healthcare technologies in their daily work. Each administrator has gained competencies according to their experience and opportunities. A few years of domain expertise make healthcare administrators competent and educated about every aspect of their profession.

According to healthcare administrators, practice and experience serve as the cornerstones on which their competencies are built. In the rapidly changing environment of digital healthcare, interdepartmental collaboration is essential for long-term success and adaptability, especially between HAs, IT personnel and medical specialists. Developing capabilities and resilience in this dynamic environment requires a diverse approach.

Mental illness typically onsets during the developmental stages from adolescence to emerging adulthood (ages 15–24 years), referred to as ‘youth’. A subset of youth with mental illness may be identified as having ‘complex’ mental health needs, defined based on requiring prolonged, extensive and resource-intensive services across multiple sectors, functional impairment, and comorbid challenges or multimorbidity . Effective early intervention for youth with complex mental illness is crucial to prevent the sequelae of long-term mental health problems. Several resource-intensive outpatient models have been developed to meet the needs of youth with complex mental illness; however, to the best of our knowledge, no scoping review has synthesised the available evidence on these interventions. A comprehensive synthesis of existing intensive outpatient interventions is needed to identify, target and inform future research and clinical efforts to better serve youth with complex mental illness. As such, the proposed scoping review will address the following research questions: (1) What intensive outpatient interventions have been evaluated for youth with complex mental illness? (2) To which populations are these interventions targeted? and (3) What outcomes have been examined within the context of these models?

This review will follow the Arksey and O’Malley framework for scoping reviews, and we will report the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) recommendations. We will conduct a comprehensive literature search across seven academic databases to identify relevant peer-reviewed material in English from 1990 to the present. Inclusion criteria will address evaluations of outpatient models of care with intensive components targeted to youth ages 15–24 with features of complex mental illness. Studies will be screened independently for eligibility by two reviewers in Covidence using clear inclusion criteria. We will then collate, summarise and present the findings to provide a comprehensive overview of the existing evidence.

Ethical approval will not be required, as no data will be collected for the proposed project. Results will be disseminated in peer-reviewed articles, presented at conferences and shared with stakeholders to inform the development, implementation and evaluation of comprehensive transdiagnostic services targeting youth with complex mental illness.

This study aimed to analyse the number of myocardial infarction (MI) admissions during the COVID-19 lockdown periods of 2020 and 2021 (March 15th to June 15th) and compare them with corresponding pre-pandemic period in 2019. The study also evaluated changes in critical treatment intervals: onset to door (O2D), door to balloon (D2B) and door to needle (D2N) and assessed 30-day clinical outcomes. This study examined MI care trends in India during the COVID-19 lockdown period, irrespective of patients’ COVID-19 infection status.

Multicentre retrospective cohort study

Twenty-three public and private hospitals across multiple Indian states, all with 24/7 interventional cardiology facilities.

All adults (>18 years) admitted with acute myocardial infarction between March 15 and June 15 in 2019 (pre-pandemic), 2020 (first lockdown) and 2021 (second lockdown). A total of 3614 cases were analysed after excluding duplicates and incomplete data.

Number of MI admissions, median O2D, D2B and D2N times.

30-day outcomes including death, reinfarction and revascularisation.

MI admissions dropped from 4470 in year 2019 to 2131 (2020) and 1483 (2021). The median O2D increased from 200 min (IQR 115–428) pre-COVID-19 to 390 min (IQR 165–796) in 2020 and 304 min (IQR 135–780) in 2021. The median D2B time reduced from 225 min (IQR 120–420) in 2019 to 100 min (IQR 53–510) in 2020 and 130 min (IQR 60–704) in 2021. Similarly, D2N time decreased from 240 min (IQR 120–840) to 35 min (IQR 25–69) and 45 min (IQR 24–75), respectively. The 30-day outcome of death, reinfarction and revascularisation was 4.25% in 2020 and 5.1% in 2021, comparable to 5.8% reported in the Acute Coronary Syndrome Quality Improvement in Kerala study.

Despite the expansion of catheterisation facilities across India, the country continues to fall short of achieving international benchmarks for optimal MI care.

Oral diseases are a major contributor to global disability but remain largely neglected in health policy, especially in low- and middle-income countries. India carries a disproportionately high burden of dental caries and periodontal disease, with limited access to oral healthcare and high reliance on out-of-pocket expenditure (OOPE). Despite this, there is a lack of synthesised economic evidence specific to India, which limits informed policymaking and resource allocation. This systematic review aims to assess the economic burden and financial impact of oral diseases in India—at individual, household, health system and societal levels—focusing on direct and indirect costs, including OOPE and catastrophic health expenditure (CHE).

This review will follow the JBI methodology for economic evaluation evidence and adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. A three-step search strategy will be used to identify relevant studies from databases, including MEDLINE (Ovid), Embase, Scopus, CINAHL (Ovid), Dentistry and Oral Sciences Source (EBSCO) and Cochrane CENTRAL, as well as grey literature sources.

We will include studies conducted in India that report on the economic burden or financial impact of oral diseases at the individual, household or population level. Eligible designs include cost-of-illness studies, cost analysis, cost-outcome analysis and health expenditure analysis using cross-sectional (including repeated cross-sectional) or cohort designs, as well as analyses based on secondary datasets. Studies using econometric, statistical or modelling methods, with or without comparators, will be included. Mixed-methods studies will be eligible if they provide extractable quantitative data.

Two reviewers will independently screen and appraise studies using JBI critical appraisal tools suited to each study design. Data extraction will focus on direct and indirect costs, including OOPE and financial impacts, such as CHE, hardship financing and poverty effects. Findings will be presented narratively and, where feasible, pooled in a meta-analysis using MetaXL V.5 software.

This review does not involve the collection or analysis of individual patient data. Instead, it will use data from publicly available economic research studies. All data sources will be appropriately cited. Extracted data will be systematically curated and managed using version-controlled spreadsheets and reference software. As this is a secondary analysis of published literature, ethical approval is not required. Findings will be disseminated through peer-reviewed publications and scientific presentations, as well as shared with policymakers and community health organisations via policy briefs and stakeholder outreach.

CRD420251030651.

Recent studies have demonstrated a beneficial role of steroids in severe community-acquired pneumonia, severe COVID-19 infection and acute respiratory distress syndrome (ARDS) of diverse aetiology. This multicentre randomised controlled trial in severe scrub typhus pneumonitis and ARDS will compare the effects of 6 mg of dexamethasone once per day with placebo, in addition to standard treatment, on ventilator-free days (VFD), mortality and ventilatory requirement.

The study, involving six sites, will recruit 440 patients with severe scrub typhus pneumonitis or ARDS to concealed, block-randomised, site-specific assignment of dexamethasone or placebo for 4–7 days. The primary outcome will be VFD, defined as days alive and free of ventilation at 28 days. Secondary outcomes will include 28-day mortality, need and duration of ventilation, and treatment failure, defined as death, or escalation of respiratory support from simple devices (nasal cannula, mask) to non-invasive or invasive ventilation, or the use of open-labelled steroids for worsening shock. The study will also ascertain if antinuclear antibody (ANA) expression during the acute phase of illness will predict steroid responsiveness. Subgroup analyses will be conducted a priori on ANA expression and the need for ventilation. All analyses will be conducted on an intention-to-treat basis. The trial, which commenced in April 2025, would clarify the role of corticosteroids in scrub typhus pneumonitis.

The Institutional Review Board and Ethics Committee of the lead site, Christian Medical College, Vellore, India, has approved the study (IRB Min No 15920 (INTERVE) dated 22 November 2023). The remaining five sites have obtained approval from their respective ethics committees. Study results will be published in an international peer-reviewed journal.

CTRI/2024/12/077709. Registered 5 December 2024.

To assess the implementation feasibility and acceptability of a structured digital psychosocial communication tool (DIALOG+) to strengthen the quality of person-centric care in psychiatric settings within Pakistan and India.

A hybrid inductive and thematic qualitative analysis using individual interviews (IDIs) and focus group discussions (FGDs).

Two psychiatric hospitals (Karwan-e-Hayat and Jinnah Postgraduate Medical Centre) in Karachi, Pakistan and one psychiatric care organisation (Schizophrenia Research Foundation) in Chennai, India

Interviews were conducted with 8 mental health clinicians and 40 patients who completed the DIALOG+ pilot as well as wider stakeholders, that is, 12 mental health clinical providers, 15 caregivers of people with psychosis and 13 mental health experts.

A technology-assisted communication tool (DIALOG+) to structure routine meetings and inform care planning, consisting of monthly sessions over a period of 3 months. The intervention comprises a self-reported assessment of patient satisfaction and quality of life on eight holistic life domains and three treatment domains, followed by a four-step solution-focused approach to address the concerns raised in chosen domains for help.

Key insights for the implementation feasibility and acceptability of DIALOG+ were assessed qualitatively using inductive thematic analysis of 22 IDIs and 8 FGDs with 54 individuals.

Clinicians and patients ascribed value to the efficiency and structure that DIALOG+ introduced to consultations but agreed it was challenging to adopt in busy outpatient settings. Appointment systems and selective criteria for who is offered DIALOG+ were recommended to better manage workload. Caregiver involvement in DIALOG+ delivery was strongly emphasised by family members, along with pictorial representation and relevant life domains by patients to enhance the acceptability of the DIALOG+ approach.

Findings highlight that the feasibility of implementing DIALOG+ in psychiatric care is closely tied to strategies that address clinician workload. Promoting institutional ownership in strengthening resource allocation is essential to reduce the burden on mental health professionals in order to enable them to provide more patient-centric and holistic care for people with psychosis. Further research is required to explore the appropriateness of including caregivers in DIALOG+ delivery to adapt to communal cultural attitudes in South Asia.

To identify the minimum effective dose of a multi-behaviour change technique (BCT) intervention to increase physical activity among individuals on primary statin therapy using the time-to-event continual reassessment method (TiTE-CRM).

A large New York metropolitan area healthcare system comprising approximately 85 000 employees and 5.5 million patient encounters annually.

42 participants enrolled in 13 cohorts of 3 participants, 1 cohort of 2 participants and 1 cohort of 1 participant. The sample was composed of 16.7% individuals aged 66 and older (n=7), 64.3% women (n=27), 69.0% white individuals (n=29) and 7.1% Hispanic individuals (n=3).

A variable-duration, four-BCT text message intervention and a 2-week follow-up. Dose assignment relied on TiTE-CRM to adjust the duration of the intervention based on adherence of participants in prior cohorts. Five mechanisms of action (MoAs) were assessed: self-efficacy, intrinsic regulation, discrepancy in behaviour, motivation and barriers to activity.

The primary outcome measure was the proportion of participants who achieved a 2000 step/day increase between baseline and follow-up. The secondary outcomes were within-participant changes in daily steps (examined as a continuous variable at the daily level) and potential MoAs for increased physical activity.

Of the 40 participants who completed follow-up, 7 (17.5%) achieved the goal of 2000 or more steps per day during their follow-up period. Though participants did increase the number of steps they walked during the intervention (B(SE)=373.1 (154.7) steps; p=0.016), there was no association between increased intervention duration and increased daily average steps. The intervention was also associated with increases in self-efficacy (p=0.002), intrinsic regulation (p=0.037), discrepancy in behaviour (p

The results of this trial did not show a traditional dose-response curve to increasing the length of a multicomponent BCT intervention. Results did show that the intervention successfully increased steps during the intervention period and that the benefit of the intervention dwindled during follow-up. Further, potential MoAs for the intervention were confirmed.

NCT05273723.

Chronic inflammatory skin diseases, despite low mortality, significantly impair quality of life (QoL). Up to 80% of patients with dermatological conditions experience severe itch and poor sleep, as well as related mental health challenges such as anxiety and depression. The relationship between skin diseases and mental health highlights the challenges that doctors face in treating these conditions. Existing psychotherapeutics, such as mindfulness training, cognitive behavioural therapy and acceptance and commitment therapy, are widely used and effective in the treatment of mental health illnesses. However, there is limited evidence on the application of such interventions in dermatology, and most mental health apps lack robust clinical evaluation. We report the design of a randomised controlled trial to evaluate the efficacy and implementation of a mobile app containing dermatology-specified psychotherapeutic strategies in reducing QoL burden.

English-speaking patients aged 16 years and older with psoriasis, eczema or chronic urticaria will be recruited and randomised into the intervention arm (psychotherapeutic application) or active control group (Healthy365 app, a general wellness application managed by the Singapore Health Promotion Board). This allows a comparative assessment of app-usage-specific outcomes while preserving the blinding of all participants. The primary outcome is the change in the Dermatology Life Quality Index (DLQI) score from baseline to week 8. Secondary outcomes include physician-assessed disease severity at weeks 8 and 16 relative to baseline, differences in other patient-reported measures at weeks 8, 16 and 32, self-reported treatment adherence and initiation/escalation of systemic medications. To understand how patients engage with the app, we will evaluate the implementation process, focusing on key measures such as engagement, satisfaction and willingness to pay. Statistical analysis will be carried out on an intention-to-treat basis, and missing data will be analysed using last observation carried forward.

All participants will receive both verbal and written study information that aligns with Good Clinical Practice guidelines. Ethical approval has been obtained from the National Healthcare Group’s Domain Specific Review Board (reference number: 2022/00751). Results will be disseminated via publication in a relevant journal. Data will be available from the corresponding author on reasonable request.

NCT06702293.

Gambling is now widely acknowledged to be a major public health (PH) issue. The Office for Health Improvement and Disparities conservatively estimated that gambling harm is associated with an annual cost of £1.05–£1.77 billion in England alone. Marionneau et al have categorised gambling harms into seven themes: (1) financial, (2) relationship/conflict, (3) emotional and psychological (mental health), (4) health decrements (physical health), (5) employment/education, (6) cultural and (7) criminal activity. In this understanding, gambling harms are not restricted to individual experiences: they also impact families, the wider community and society, and hence they require a whole systems, PH approach, anchored in population-level interventions to reduce harms. We aim to identify the effects of interventional PH laws and regulations on the harms associated with gambling.

We limit our focus to interventional PH laws and regulations within a comprehensive search of scientific and legal databases, grey literature and books. Following Population, Intervention, Comparator, Outcome, Study, Timing inclusion criteria, evidence will be screened and appraised in Covidence by two reviewers (MF and TP). Included evidence will be analysed and synthesised using a narrative synthesis approach. Methodological quality will be appraised using the relevant risk of bias tool. Randomised controlled trials will be assessed using the Cochrane risk of bias tool (RoB2), Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) will be used for other non-randomised studies. Qualitative studies will be appraised using the EPPI reviewer software for systematic reviewing.

The review protocol is registered with PROSPERO (International prospective register of systematic reviews) at the National Institute for Health Research and the Centre for Reviews and Dissemination (CRD) at the University of York (CRD42024574502). We aim to define a theory of change and produce a context-mechanism-outcome framework with relevant experts using the findings. We plan to disseminate the findings through peer-reviewed publications, meetings with relevant experts and international conference presentations.