Background: 'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence. Methods: First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness. Results: We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients.

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Background Guidelines recommend involving intervention users in the intervention development process. However, there is limited guidance on how to involve users in a meaningful and effective way. Objective The aim of this Study within a trial was to compare participants’ experiences of taking part in one of three types of consensus meetings—people with diabetes‐only, combined people with diabetes and health‐care professionals (HCPs) or HCP‐only meeting. Design The study used a mixed methods convergent design. Quantitative (questionnaire) and qualitative (observation notes and semi‐structured telephone interviews) data were collected to explore participants’ experiences. A triangulation protocol was used to compare quantitative and qualitative findings. Participants People with diabetes (recruited via multiple strategies) were randomly assigned to attend the people with diabetes or combined meeting. HCPs (recruited through professional networks) attended the HCP or combined meeting based on their availability. Results Sixteen people with diabetes and 15 HCPs attended meetings, of whom 18 participated in a telephone interview. Participants’ questionnaire responses suggested similar positive experiences across the three meetings. Observation and semi‐structured interviews highlighted differences experienced by participants in the combined meeting relating to: perceived lack of common ground; feeling empowered versus undervalued; needing to feel safe and going off task to fill the void. Conclusions The qualitative theme ‘needing to feel safe’ may explain the dissonance (disagreement) between quantitative and qualitative data. In this study, involving patients and HCPs simultaneously in a consensus process was not found to be as suitable as involving each stakeholder group separately.

Globally, household and ambient air pollution (HAAP) leads to approximately seven million premature deaths per year. One of the main sources of household air pollution (HAP) is the traditional stove. So-called improved cookstoves (ICS) do not reduce emissions to levels that benefit health, but the poorest communities are unlikely to have access to cleaner cooking in the medium term. Therefore, ICS are being promoted as an intermediate step. This paper summarises the current evidence on the ICS available to the global poorest, utilising data from the Clean Cookstoves Catalog and systematic review evidence from the field. The cheapest stoves offer little reduction in HAP. Only one ICS, available at US$5 or less, (the canarumwe) minimally reduced pollutants based on ISO testing standards and no studies included in the systematic reviews reported tested this stove in the field. We recommend field testing all ICS as standard, and clear information on stove characteristics, sustainability, safety, emissions efficiency, in-field performance, affordability, availability in different settings, and the ability of the stove to meet community cooking needs. In addition, ICS should be promoted alongside a suite of measures, including improved ventilation and facilities to dry wood, to further reduce the pollutant levels.

Household air pollution (HAP), primarily from biomass fuels used for cooking, is associated with adverse health outcomes and premature mortality. It affects almost half of the world’s population, especially in low-income and low-resourced communities. However, many of the ’improved’ biomass cookstoves (ICS) aimed at reducing HAP lack empirical evidence of pollutant reduction and reliability in the field. A scoping review guided by the Joanna Briggs Institute framework was systematically conducted to explore and analyse the characteristics of cookstoves to assess the ICS available to meet the socio-economic and health needs of households in sub-Sahara Africa (sSA). The review searched Scopus, PubMed, Web of Science, EMBASE, Global Health Database on OVID, BASE, and conducted a grey literature search from 2014 to 2022 for all field-based ICS studies. In addition, user perspectives were explored for cookstoves analysed as available, affordable, and effective in reducing harmful biomass emissions. The search returned 1984 records. Thirty-three references containing 23 ICS brands were included. The cookstoves were analysed into seven categories: (1) efficiency in HAP reduction, (2) availability, (3) affordability, (4) sustainability, (5) safety, (6) health outcomes, and (7) user experience. Most (86.9%) of the improved cookstoves showed a reduction in harmful emission levels compared to the traditional three-stone fire. However, the levels were higher than the WHO-recommended safe levels. Only nine were priced below 40 USD. Users placed emphasis on cookstoves’ suitability for cooking, fuel and time savings, safety, and price. Equality in cooking-related gender roles and psychosocial benefits were also reported. The review demonstrated limited field testing, a lack of evidence of ICS emissions in real-life settings in sSA, heterogeneity in emission measurements, and incomplete descriptions of ICS and kitchen features. Gender differences in exposure and psychosocial benefits were also reported. The review recommends improved cookstove promotion alongside additional measures to reduce HAP at a cost affordable to low-resource households. Future research should focus on detailed reporting of study parameters to facilitate effective comparison of ICS performance in different social settings with different local foods and fuel types. Finally, a more community-based approach is needed to assess and ensure user voices are represented in HAP intervention studies, including designing the cookstoves.

BackgroundHousehold air pollution (HAP) kills 4 million annually, with access to clean cooking being a challenge for 37% of the world’s population. Whilst there have been advancements in improved biomass cookstove (ICS) technologies, reviews on the impact of these ICS on HAP are now more than three years old.ObjectivesThis review and meta-analysis examines the most recent evidence on the impact of ICS on HAP and blood pressure (BP).MethodsA literature search was conducted using scientific literature databases and grey literature. Studies were included if they were published between January 2012 and June 2020, reported impact of ICS interventions in non-pregnant adults in low/middle-income countries, and reported post-intervention results along with baseline of traditional cookstoves. Outcomes included 24- or 48-hour averages of kitchen area fine particulate matter (PM2.5), carbon monoxide (CO), mean systolic BP (SBP) and mean diastolic BP (DBP). Meta-analyses estimated weighted mean differences between baseline and post-intervention values for all outcome measures.ResultsNine studies were included; eight contributed estimates for HAP and three for BP. Interventions lead to significant reductions in PM2.5 (−0.28 mg/m3, 95% CI: -0.46, -0.10), CO (−6.59ppm, 95%CI: - 10.73, -2.46) and SBP (−2.82mmHg, 95% CI: -5.53, -0.11); and a non-significant reduction in DBP (−0.80 mmHg, 95%CI: -2.33, 0.73), when compared to baseline of traditional cookstoves. Except for DBP, greatest reductions in all outcomes came from standard combustion ICS with a chimney, compared to ICS without a chimney and advanced combustion ICS. WHO air quality targets were met by post-intervention values for CO but not for PM2.5.ConclusionOur review suggests that ICS with a chimney results in the greatest reductions in HAP and BP. Further research on qualitative impact of such ICS on end-users is required to understand feasibility of adoption at scale.

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Aim Globally, household and ambient air pollution (HAAP) accounts for almost 7 million premature deaths each year. Over half of these are from incomplete biomass fuel combustion in open fires and inefficient cookstoves. Solutions to the problem remain challenging due to cost, people’s perception of pollution and unsuitability to meet user needs. Subject and methods We used mixed methods and participatory approaches to measure and understand practices and beliefs relating to HAAP in a low-resource community in Malawi. Eighty-six households were randomly sampled for the survey, fine particulate matter (PM2.5) levels were measured in 46 kitchens and four ambient locations, and 38 households were engaged during participatory transect walks. We analysed the data using descriptive and thematic analysis. Results Kitchen PM2.5 levels far exceeded the World Health Organization’s recommended safe levels. Open-burning practices further contributed to ambient air pollution in the community. While there was high awareness of smoke in cooking areas, participants did not associate it with adverse health outcomes. Availability and affordability of cleaner alternatives influenced household energy choices. Integrating participatory methods alongside quantitative data allowed an in-depth understanding of the community’s practices and relationship with HAAP. Conclusion The findings demonstrate that energy poverty is a key factor in access to clean energy sources and highlight the importance of engaging communities to design HAAP interventions that meet their physical, socioeconomic and cultural needs.