BackgroundUptake of preschool vaccinations is less than optimal. Financial incentives and quasi-mandatory policies (restricting access to child care or educational settings to fully vaccinated children) have been used to increase uptake internationally, but not in the UK.ObjectiveTo provide evidence on the effectiveness, acceptability and economic costs and consequences of parental financial incentives and quasi-mandatory schemes for increasing the uptake of preschool vaccinations.DesignSystematic review, qualitative study and discrete choice experiment (DCE) with questionnaire.SettingCommunity, health and education settings in England.ParticipantsQualitative study – parents and carers of preschool children, health and educational professionals. DCE – parents and carers of preschool children identified as ‘at high risk’ and ‘not at high risk’ of incompletely vaccinating their children.Data sourcesQualitative study – focus groups and individual interviews. DCE – online questionnaire.Review methodsThe review included studies exploring the effectiveness, acceptability or economic costs and consequences of interventions that offered contingent rewards or penalties with real material value for preschool vaccinations, or quasi-mandatory schemes that restricted access to ‘universal’ services, compared with usual care or no intervention. Electronic database, reference and citation searches were conducted.ResultsSystematic review – there was insufficient evidence to conclude that the interventions considered are effective. There was some evidence that the quasi-mandatory interventions were acceptable. There was insufficient evidence to draw conclusions on economic costs and consequences. Qualitative study – there was little appetite for parental financial incentives. Quasi-mandatory schemes were more acceptable. Optimising current services was consistently preferred to the interventions proposed. DCE and questionnaire – universal parental financial incentives were preferred to quasi-mandatory interventions, which were preferred to targeted incentives. Those reporting that they would need an incentive to vaccinate their children completely required around £110. Those who did not felt that the maximum acceptable incentive was around £70.LimitationsSystematic review – a number of relevant studies were excluded as they did not meet the study design inclusion criteria. Qualitative study – few partially and non-vaccinating parents were recruited. DCE and questionnaire – data were from a convenience sample.ConclusionsThere is little current evidence on the effectiveness or economic costs and consequences of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. Universal incentives are likely to be more acceptable than targeted ones. Preferences concerning incentives versus quasi-mandatory interventions may depend on the context in which these are elicited.Future workFurther evidence is required on (i) the effectiveness and optimal configuration of parental financial incentive and quasi-mandatory interventions for preschool vaccinations – if effectiveness is confirmed, further evidence is required on how to communicate this to stakeholders and the impact on acceptability; and (ii) the acceptability of parental financial incentive and quasi-mandatory interventions for preschool vaccinations to members of the population who are not parents of preschool children or relevant health professionals. Further consideration should be given to (i) incorporating reasons for non-vaccination into new interventions for promoting vaccination uptake; and (ii) how existing services can be optimised.Study registrationThis study is registered as PROSPERO CRD42012003192.FundingThe National Institute for Health Research Health Technology Assessment programme.

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ObjectivesSex and relationship education (SRE) is regarded as vital to improving young people’s sexual health, but a third of schools in England lacks good SRE and government guidance is outdated. We aimed to identify what makes SRE programmes effective, acceptable, sustainable and capable of faithful implementation.DesignThis is a synthesis of findings from five research packages that we conducted (practitioner interviews, case study investigation, National Survey of Sexual Attitudes and Lifestyles, review of reviews and qualitative synthesis). We also gained feedback on our research from stakeholder consultations.SettingsPrimary research and stakeholder consultations were conducted in the UK. Secondary research draws on studies worldwide.ResultsOur findings indicate that school-based SRE and school-linked sexual health services can be effective at improving sexual health. We found professional consensus that good programmes start in primary school. Professionals and young people agreed that good programmes are age-appropriate, interactive and take place in a safe environment. Some young women reported preferring single-sex classes, but young men appeared to want mixed classes. Young people and professionals agreed that SRE should take a ‘life skills’ approach and not focus on abstinence. Young people advocated a ‘sex-positive’ approach but reported this was lacking. Young people and professionals agreed that SRE should discuss risks, but young people indicated that approaches to risk need revising. Professionals felt teachers should be involved in SRE delivery, but many young people reported disliking having their teachers deliver SRE and we found that key messages could become lost when interpreted by teachers. The divergence between young people and professionals was echoed by stakeholders. We developed criteria for best practice based on the evidence.ConclusionsWe identified key features of effective and acceptable SRE. Our best practice criteria can be used to evaluate existing programmes, contribute to the development of new programmes and inform consultations around statutory SRE.

ObjectivesTo evaluate the effectiveness of a complex intervention to improve referral and treatment of pregnant smokers in routine practice, and to assess the incremental costs to the National Health Service (NHS) per additional woman quitting smoking.DesignInterrupted time series analysis of routine data before and after introducing the intervention, within-study economic evaluation.SettingEight acute NHS hospital trusts and 12 local authority areas in North East England.Participants37 726 records of singleton delivery including 10 594 to mothers classified as smoking during pregnancy.InterventionsA package of measures implemented in trusts and smoking cessation services, aimed at increasing the proportion of pregnant smokers quitting during pregnancy, comprising skills training for healthcare and smoking cessation staff; universal carbon monoxide monitoring with routine opt-out referral for smoking cessation support; provision of carbon monoxide monitors and supporting materials; and an explicit referral pathway and follow-up protocol.Main outcome measuresReferrals to smoking cessation services; probability of quitting smoking during pregnancy; additional costs to health services; incremental cost per additional woman quitting.ResultsAfter introduction of the intervention, the referral rate increased more than twofold (incidence rate ratio=2.47, 95% CI 2.16 to 2.81) and the probability of quitting by delivery increased (adjusted OR=1.81, 95% CI 1.54 to 2.12). The additional cost per delivery was £31 and the incremental cost per additional quit was £952; 31 pregnant women needed to be treated for each additional quitter.ConclusionsThe implementation of a system-wide complex healthcare intervention was associated with significant increase in rates of quitting by delivery.