Improving Health Outcomes for Care Leavers: the Life in Transition (LIFT) cluster-randomised feasibility trial

Improving Health Outcomes for Care Leavers: the Life in Transition (LIFT) cluster-randomised feasibility trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Improving Health Outcomes for Care Leavers: the Life in Transition (LIFT) cluster-randomised feasibility trial Professor Geraldine Macdonald, Jacqueline Hammond, Fiona Lynn, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8000798/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background Inequalities in health amongst care-experienced young people span all aspects of health, including mental health and wellbeing. We developed an intervention to better equip Personal Advisors (staff with statutory responsibility for supporting Care Leavers) to address a range of health issues. The study aimed to assess the acceptability of the intervention and the feasibility of conducting a definitive cluster randomised trial. Methods This 24-month study took place in three local authorities (LAs) between 2022 and 2024. Two LAs were in the South West of England, the third was in the East Midlands. Two of the three Personal Advisor teams in each LA were randomised to receive the training, which comprised six online modules and a one-day skills workshop facilitated by health professionals. Study participation was voluntary but all staff in the intervention arm were expected to complete the training. Control teams received no training. Our objectives were to evaluate the feasibility of recruitment and retention of both Personal Advisors (PAs) and Care leavers (CLs), data collection (by peer researcher and research staff), the acceptability and cost of the intervention and the general demands of the study. We conducted qualitative interviews with PAs and CLs. Results We recruited 63 of 76 eligible PAs and 71 CLs. 52 CLs (73%) completed the final follow up interview. CLs were typically female, white with a mean age of 19 years. Just over half were not in education, employment, or training. The intervention was broadly acceptable, but some PAs reported difficulties in finding the time to complete the modules, despite a commitment by managers of protected time to do so. Some PAs said they were already familiar with some module content. The demands of the trial were generally judged to be acceptable to CLs and to PAs. Delays incurred by the REDCap team meant that we had to stagger the recruitment of PAs and CLs. This extended the number of requests to LA staff, which some found irksome. Plans to use peer researchers had to be abandoned for logistical reasons. Conclusions The results demonstrate the feasibility of conducting a cluster randomised trial in children’s social care. Trial registration ISRCTN, ISRCTN11518804. Registered 13 January 2023, https://www.isrctn.com/ISRCTN11518804 Cluster randomised trial feasibility trial care leavers personal advisors health Figures Figure 1 Key messages regarding feasibility What uncertainties existed regarding the feasibility? Staff known as Personal Advisors (PAs) have a statutory duty to support care leavers in their transition from care to independent living. Such support includes care leavers’ health and wellbeing, including their emotional health. Evidence from care leavers suggests that Personal Advisors attend less to their health issues than to other areas, such as housing, education and employment, and a survey of local authorities in England and Northern Ireland indicated that personal advisors receive little, if any, training in how to support care leavers that would maximise their health outcomes. We wanted to know whether a brief training programme comprising six online modules and a one-day in-person skills training provided by health professionals, could improve the health support provided to care leavers by PAs. What are the key feasibility findings? We had no difficulty recruiting local authorities, personal advisors or care leavers to participate in a cluster randomised trial. Almost all PAs agreed to participate and we recruited more care leavers than planned. Retention was also good, and it is in principle possible to mask outcome assessors, although limited resources and exploration of the experience of participating in the trial meant this was not entirely possible in this feasibility trial. Feedback from PAs suggests the approach to training was acceptable, although some said they were already familiar with the content of some modules, and some said it was difficult to prioritise the online modules over more pressing practice matters. Despite an agreement from managers to allocated protected time for the training, this was not achieved in every agency. The in-person skills sessions were valued for the focus on how to raise and address health issues, and the opportunity to learn from health professionals and from one another. The key problem to emerge related to the outcome measures chosen and their performance. It proved difficult to identify one measure that could capture the diverse range of effects that the intervention might have across a large group of care leavers, and that were sensitive to the specific effect in each individual. What are the implications of the feasibility findings for the design of the main study? The study indicates that it is possible to undertake randomised controlled trials in children’s social care. The intervention, whilst acceptable to participants, might be more accessible if each module was shorter. Given the return to face-to-face training in many areas, it might be sensible to consider providing the module content in in-person workshops. Whether online or in-person, it would be helpful to incorporate some before-and-after measures of understanding in order to better monitor the delivery and impact of the training. Ensuring each PA was represented by at least one of their care leavers participating in the study would ensure that outcome measures completed by the care leavers captured the effect of the intervention on the whole PA team. Recruitment of care leavers by the study team, rather than via PAs, would help ensure a representative sample of care leavers, and preliminary work with team leaders might help to embed learning in practice. A main trial would need to identify measures that were sufficiently sensitive to identify improvement in care leavers’ general well-being or – given the long-term follow-up required to achieve this - to more robustly identify improvements in knowledge and practice amongst PAs. Background Inequalities in health amongst care-experienced children and young people span all aspects of health. Despite improvements in recent years, and recognising the difficulties in comparisons with the general population, looked after children remain less likely to have received all routine immunizations, ( 1 , 2 ) with lowest rates amongst older looked-after children and unaccompanied asylum-seeking children. ( 3 , 4 ) They are at greater risk of early sexual initiation ( 5 ) and of sexual exploitation, ( 6 ) more likely to become pregnant and to become parents at an early age. ( 7 – 10 ) Care experienced young women are more likely to smoke during pregnancy, to have symptoms of depression and deliver a low birthweight baby.( 11 ) They may be at increased risk for pre-term birth ( 12 , 13 ) and to have an elevated risk of their own children being taken into care, ( 14 ) with a significant number experiencing recurrent care proceedings. ( 15 ) A systematic review of studies estimating the prevalence of mental health disorders among children and young people in care in the UK demonstrated that estimates vary considerably ( 16 ) but there is general agreement that the mental health of children in care is poorer than that of comparable peers (e.g. 17). Many children enter care with existing mental health problems, often associated with trauma ( 18 – 20 ) and the Departments of Education and Health estimate that almost a half of LACYP have a diagnosable mental health disorder.( 21 ) In 2021, researchers compared the inequalities of health and social functioning between adults who had experienced time in care (the ‘non-parental care group’) and a group cared for solely by their parents (the ‘parental care group’). Using data collected between 1971 and 2011 the team looked at the impact of care experience and placement type on a range of outcomes, including self-rated health, limiting long-standing illness, all-cause mortality and cause of death. Adults with care experience reported poorer health and more limiting long-standing illness than those without, were more likely to die form ‘unnatural causes, such as suicide, drug overdoses, alcoholism, car accidents and assaults.( 22 , 23 ) They estimated that the risk of premature death for care experienced adults was 62% higher than for those in parental care. This only dropped to 43% when controlling for differences in socio-economic status. The UK National Service Framework for Children, Young People and Maternity Services recognises children and young people in care as a particularly vulnerable group.( 24 ) Various policy initiatives have sought to improve their physical, sexual and mental health. The introduction of the looked-after children (LAC) ‘named nurse’ represented a significant investment in promoting the health of children whilst in care, but that support can no longer be accessed when young people leave care. Care leavers Every year, some 10,000 children aged 16–18 years leave local authority (LA) care in England ( 10 ) and many start to lead independent lives. Most make the transition against a background of significant adversity and trauma, having been removed from the care of their parents due to abuse and neglect. ( 25 , 26 ) Transition to adult services and responsibility for their own health care takes place much earlier than it does for most young people, and for those in care it can happen very suddenly. ( 27 ) Those with mental health needs are likely to find themselves without support at a time they need it most, and many care leavers face loneliness and isolation. In this arrangement of service provision, young people are faced with a system that is ‘weakest where it needs to be strongest’.( 28 ) A health survey completed by 418 care leavers found that 44% stated they regularly drank alcohol to excess and 29% had self-harmed. ( 29 ) They felt that their health needs were not understood and they had found it difficult to access adult services. Care leavers are more likely than those who have not been in care to engage in risky behaviours, such as smoking, substance use and misuse, and unprotected sex. They are over-represented amongst the homeless, ( 30 , 31 ) among young women who become teenage parents,( 32 ) those who self-harm, ( 33 , 34 ) and those involved with the criminal justice system.( 31 ) The most common theme reported in all studies of care leavers’ views are feelings of isolation and loneliness. There are also significant societal costs. For example, mothers who are CLs are at increased risk of parenting problems and unstable housing arrangements,( 11 , 35 ) and their children are more likely to be taken into care,( 14 ) leading some women to avoid involvement with services. ( 36 , 37 ) Using the costs to young people of not being in education, employment and training (NEET), the NAO estimated lifetime cost of the 2015 cohort of 19-year old care leavers to be around £240 million - £150 million more than if they had the same NEET rate as 19 year old young people who had not been in care.(38p7) Personal Advisors Local Authorities (LAs) are mandated to provide a Personal Advisor (PA) to support care leavers up to the age of 25. PAs are expected to ensure that care leavers have the support they need, and to coordinate and review the services needed to implement the young person’s ‘Pathway Plan’. The Pathway Plan is required for all care leavers; it is designed to facilitate successful transition( 39 ) and covers 8 eight areas of their lives, including their ‘health and development’ and ‘emotional and behavioural development’. The Pathway Plan should include details of a young person’s health needs and how these should be met, and the development of this plan should be supported by annual Health Assessments undertaken while in care. Care Leavers should be provided with a Health Passport when they leave care, summarizing their health history and needs for their own future reference. PAs are expected to take reasonable steps to ensure that the young person makes use of the services identified in the Pathway Plan and to remain informed about their progress and wellbeing. ( 40 ) The expectations of the PA are set out in the Children and Social Work Act 2017 and in the description of the ‘named worker’ in NICE guideline NG43.( 41 ) Statutory guidance ( 21 ) makes clear that PAs ‘should have access to information and training about how to promote physical and mental health’ (p.26), to work in partnership with CLs and those health professionals involved in their health assessments, and to ensure that CLs have all the information they need to manage their own health. For those with complex needs, including disabilities, who do not meet the criteria for support by adult services, the PA should ensure that all possible forms of support are identified and made available. Despite the statutory force of the guidance, health is rarely a major focus for PAs, who are primarily concerned with basic provision of housing and money. ( 42 , 43 ) Whilst appropriate accommodation is essential for mental and physical health and wellbeing, many care leavers report that insufficient attention is given to their health needs, particularly their mental health needs and as the Care Quality Commission noted, most lack adequate health support.(44 p.36) As adults with whom CLs have (ideally) already formed a supportive relationship, the PA is well placed to promote their health and wellbeing, and their use of health services. However, PA provision varies considerably across LAs, ( 32 ) and there is currently no prescribed professional qualification for PAs, other than to have a working knowledge of the issues a care leaver might face as they make their transition into adulthood, and the legal framework in relation to this. Little is known about in-service training provided by LAs, or the supervisory arrangements in place to support them in executing their role. Without an explicit curriculum to equip PAs to address issues of health and wellbeing, it is unsurprising that these issues are seldom addressed. In preparing their transition Guideline in 2016, ( 41 ) NICE was unable to identify any studies on the effectiveness of ‘transition training’ for practitioners responsible for supporting young people using children’s health or social care services ‘before, during and after transition’ (2.9) The Care Leavers Association has recommended better training for PAs, particularly in relation to mental health. Aims The aim of the Improving Health Outcomes for Care Leavers: the Life in Transition (LIFT) study was to establish the feasibility and acceptability of a future, definitive trial of the effectiveness and cost-effectiveness of a brief training programme designed to better equip Personal Advisors (PAs) to support care leavers (CLs) with a wide range of health issues. Conducting randomised trials in local authority children’s services departments can be challenging ( 45 – 47 ) and the study was designed to address two key aims: (i) to explore the views of personal advisors on the relevance and acceptability of the training and (ii) to ascertain whether a pragmatic trial was feasible. Our primary objective was to ascertain the feasibility of key procedural elements that would need to form part of an experimental evaluation of the effectiveness of the training intervention, including: whether it is possible to train and retain all PAs in each participating authority; whether it is possible to recruit and retain a sample of CLs in each arm of the study to a 12 months follow-up, and whether it is possible to secure blinding of outcome assessors. Our secondary objectives were to Establish the acceptability and feasibility (data burden and cost), and the factors influencing the completion of measures at baseline (PAs and CLs), post training (PAs) and follow up (PAs and CLs). Collect outcome measures and assess their performance and quality with this population (acceptability, completeness, means, variability and distribution of scores). Use the data collected to estimate the Intra-cluster Correlation Coefficient (ICC) to inform the sample size requirements for a main trial. Determine the feasibility and cost of accessing and using administrative data, if available Ascertain the acceptability of randomisation to LAs and PAs Consider the implications of any contamination between the two arms of the trial e.g. PAs moving between teams in different trial groups. Identify barriers and facilitators to implementation of, and fidelity to, the intervention. To use the information gathered to inform the design of a pragmatic trial, if this seems feasible, including establishing appropriate progression criteria for an internal pilot to the main trial. Methods Trial design and random allocation This was a multi-centre, cluster-randomised feasibility trial. We randomised at the level of PA teams within each of three local authorities, using a 2:1 allocation ratio (two teams to the intervention, one to the control group). We adopted a 2:1 ratio for a number of reasons, First, each of the three participating local authorities had three PA teams and exposing larger numbers of PAs to the training provided a stronger basis on which to assess the perceived relevance and acceptability of the training and the acceptability of the data collection demands on PAs. It also increased the feedback to the research team as to how the training might be amended or further developed. A secondary consideration was the likely acceptability of this approach to randomisation within the local authorities. Whilst every care was taken to emphasise that the study was designed to test the feasibility of the study design, and not to evaluate the training – which might or might not be effective - managers were keen to offer training to this staff group, for whom little training specifically targeted their role. The random allocation sequence was generated by CM, whilst masked to the identity of the nine participating teams, and with no involvement in recruiting LAs to the study. Hypothesised mechanism of effect On the basis of consultations with PAs and CLs, and relevant literature, we hypothesised that by improving their knowledge of a range of health issues relevant to young people transitioning from care, and developing certain skills, PAs would be more likely to recognise the health needs of care leavers, to be able to raise health matters and to talk to care leavers about health, including what they might regard as challenging topics, such as sexual health, self-harm or substance misuse. We also expected PAs to be more likely to facilitate access to health resources and to support young people to take steps to protect or improve their own heath . The logic model and theory of change developed for the intervention can be found in Supplementary File 1. Outcomes and outcome measures Possible measures were identified from a review of the literature, searches of PubMed and Web of Science, with input from the study’s Programme Management Group. Possible tools were compared, taking into account their previous use in similar populations, validation studies, language used and length. The final selection was made in consultation with experienced young people, and comprised the following: Personal wellbeing, using four questions from the ONS survey ( 48 ); Physical health status, using three questions from the ONS survey ( 49 ); Self-efficacy / confidence in securing health information and support from professionals (Health Literacy), using the 10-item Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI-10) ( 50 ); Psychological coping (Mastery), using the 7-item Pearlin Mastery Scale ( 51 ); Quality of life. We used three measures of quality of life, one in each of the three sites, to explore their relative acceptability and sensitivity to quality of life amongst this group of young people: the EuroQoL Health-related Quality of Life Measure (EQ5-5D-5L) ( 52 ), the 20-item Recovering Quality of Life (ReQoL20) ( 53 ) and the 10-item Recovering Quality of Life (ReQoLl0) ( 54 ); Health service usage, using the Client Service Receipt Inventory as the basis, which is a reliable and valid resource use measurement tool. The tool was modified to collect data on health service use only to estimate cost consequences of support from a trained PA; In addition, we asked each care leaver five questions designed to assess their perceptions of PA empathy. With the exception of health service use, the time points for data collection were baseline, 24 and 48 weeks after each baseline interview was completed. Health service use data were collected at baseline and bi-monthly telephone calls. Personal Advisors who agreed to participate in the study were asked to complete a questionnaire at baseline. This asked questions about how often health, and other topics, were covered in their contacts with care leavers, their knowledge and use of health passports, their confidence in their knowledge of key aspects of health and in raising these with care leavers, and what they saw as the barriers to supporting care leavers with health issues. Those who completed the training were asked to complete a post-training questionnaire. This covered their perceptions of the relevance of the modules to the CLs with whom they work and whether they provided sufficient knowledge to identify, raise and address the health issues covered (i.e. ‘content, ‘dose’ and ‘level’); the extent to which they think organizational factors are likely to support or impede changes to their practice, including, for example, internal factors such as caseloads; administrative systems, line management support, and external factors such as the availability, capacity and responsiveness of other services; what impact they think it might have on their practice, and how it might benefit the young people with whom they work. Qualitative data In addition to the data collected via online surveys, we interviewed a sample of personal advisors and all participating care leavers at baseline. Care leavers were also asked to be available for two further interviews at 24 and 48 weeks post-baseline data collection. Personal advisors Once training was complete, we interviewed a sample of personal advisors in both arms of the trial. For PAs in the control group the interview explored their experiences of participating in the trial, specifically their thoughts and feelings about being in the control group, including their willingness to comply with the data requests that formed part of the study; to understand the local context during the period of the study, the health issues they encounter in their work and how they respond to these, the training they have received on various health issues, and what training they needed. Those in the intervention group were also asked how helpful the training had been and in what ways, and what the barriers and facilitators were to using what they had learned. Care leavers The baseline interview with CLs explored their relationship with their PA, an overview of how they viewed their physical and mental health and wellbeing, their use of health services, the extent to which health issues are discussed with their PA and how raises them, and the use made of health passports and pathway planning. Subsequent interviews comprised the candidate outcome measures for a full trial, together with questions on the extent to which they felt their health needs (including emotional health and wellbeing) had been recognized and addressed by their PAs in the previous six months. The interviews explored how often they had seen their PA; whether PAs have brought up topics covered in training modules (including help seeking, smoking, alcohol and substance use, sexual health, nutrition and exercise); what their own health and wellbeing concerns were and whether or not they had felt able to bring these to the attention of their PA; what the response was, and how helpful their PA had been more generally in helping them to address their health issues. We also enquired how the CL felt about health issues being raised by the PA, and whether or not they subsequently took any steps to address them. At the final interview we also asked about their experiences of participating in the trial, and what their advice would be to a research team wanting to conduct a larger study. Personal Advisors The interviews with intervention PAs asked them for their views on the training (helpfulness of the component parts, coverage, ‘pitch’), other training they had received on health-related matters, or would like to receive, and questions about their use of health passports and pathway plans in their work with care leavers. Interviews with control PAs asked about caseloads, the allocation of work, the sorts of health issues they encounter and how they dealt with them, training received and training they would like, plus experience of being in the research study (their views on being in the control group, of being asked to complete surveys and be interviewed) and expectations for the future (expecting to receive the training, their views on the topic). We also asked control group PAs whether any of the young people they worked with had spoken to them about being in the study, or whether they had spoken to any intervention PAs or learned about the content of the training. Building on previous experience in using peer researchers as a means of securing high quality information from care experienced young people, we collaborated with CORAM Voice to help recruit, train and support a group of peer researchers to collect data (by telephone) from care leavers. The protocol stipulated that the peer researchers would conduct the interviews with care leavers, and in the final interview, a particular focus of the conversation was to elicit their views on the use of peer researchers, as well as the incentives offered; what information they would want to know about the findings of the trial, and in what format. Participants The intervention is directed at PAs, but the intended beneficiaries are young people leaving care. The legal definition of a care leaver is someone who has been in the care of the Local Authority for a period of 13 weeks or more spanning their 16th birthday [The Children (Leaving Care) Act 2000. Inclusion criteria CLs in the three participating local authorities (Bristol City Council, Gloucestershire County Council, and Nottinghamshire County Council) who were over the age of 16 years at baseline and allocated to a Leaving Care Team for the first time in a four month period which began 2 months prior to baseline data collection. We excluded the following groups of care leavers: care leavers who were living in foster care (other than ‘Staying Put’ foster care), who were in a residential or secure setting of any kind, or themselves had an allocated social worker for reasons other than being a care leaver (for example, as a result of being a parent themselves) and those deemed by the local authority to present a risk to themselves or to research staff. Recruitment and consent Care Leavers Each LA distributed study participant information leaflets to eligible CLS along with letters of invitation to participate in the study. In addition, a member of the research team attended drop-in sessions (or similar) organised by the LA to talk about the study in person. Care was taken to make clear that young people were not obliged to take part in the study. Following an expression of interest from a CL, a member of the research team arranged to meet with them to ascertain eligibility, ensure that they fully understood what the study entailed, and that – should they agree to participate – that they could withdraw at any time without giving any reason, and without prejudice to the services they receive. Most meetings were online or by telephone, but some were in person, depending on circumstances and the young person’s preference. Personal advisors (PAs) PAs were notified of the study by their employing authority who distributed a Participant Information Leaflet designed for local authority staff. Whilst PAs were expected by their employer to participate in the training, they were asked to consent to participate in the study. Staff were asked by senior managers to attend an online briefing session to introduce them to the study and to invite them to participate. All information provided, both written and verbal, emphasised that the study was designed to explore the impact of a training intervention rather than the practice of individual PAs or teams. Some LAs had staff who focused solely on housing support for care leavers. The training programme was available to these staff, but they were not eligible for the study. All recruitment was undertaken by the research team, supported by colleagues from the Clinical Research Network serving the area. Intervention Overview The training programme was developed by a multidisciplinary team comprising health specialists, social workers, PAs, LA managers and care experienced young people. The programme was informed by an international review of what we know about the health of care experienced young people, a national survey of PAs and their managers about what training is needed, and consultations with care experienced young people, PAs, and other stakeholders from health and other sectors. The training comprised a blend of webinars, six online modules (hosted on NIHR Learn), and a skills workshop facilitated by two health professionals, at least one of whom was familiar with children in care or care leavers. The PI met twice with intervention PAs; first to take feedback on the modules, and later to collect information on the progress they made towards achieving their personal goals, and what – if anything – the barriers and facilitators were to this (see Table 1 ). Table 1 Overview of Training for Personal Advisors Component Delivery Time required of participants Facilitated by Introduction to the training (and study) Webinar 1/Briefing 1 hour maximum Research PI Six Online Modules NIHR LEARN 3-hours LA Managers Identifying key issues Webinar 2 1.5 hours. Research PI Workshop In person One day Health professionals Action Plan Implementation Day to day practice Three weeks, part of routine practice Participants/ Skills leaders Final Group Session In person 2 hours Health professionals The modules Modules combined written information with short videos, and tasks (Supplementary File 2). Line managers agreed to allow dedicated time for PAs to complete these over the course of a couple of weeks. The skills workshop Each skills workshop was facilitated by a Named Doctor for Children in Care within each of the local authorities and another health colleague. In one site this was a GP trainee, in another an Adoption Medical Advisor, and in the third a Named Nurse. The workshop manual provided facilitators with information on the background to the study, the content of the online modules, and detailed guidance on how to deliver the workshop. The workshop aimed to help participants apply the learning from the online modules and focused specifically on the development of the skills required to raise health issues in ways that are acceptable to young people, to help young people to appreciate the importance of health, and what they can do to stay healthy and well. It began with introductions, housekeeping, the aims of the workshop and ground rules. The facilitator then presented an overview of what distinguishes effective helpers and the skills associated with effective communication e.g. conveying accurate empathy, warmth and genuineness, asking open ended questions, using affirmation, reflective listening and summarizing, asking difficult questions or raising sensitive issues, such as substance misuse, sexual health etc. This was followed by a session in which participants considered a series of vignettes and practiced key skills such as identifying open ended questions or considering ways in which they might start a conversation around a sensitive topic. The remainder of the workshop comprised a series of ‘real world’ scenarios role plays i.e. role plans based on situations faced by Personal Advisors, appropriately anonymised. Participants were divided into two or three groups (depending on the scenario) and given partial information, relevant only to the ‘character’ they were role-playing. One member of each group then played a young person and a Personal Advisor, and – where relevant – a third party, such as a health visitor. There was some flexibility afforded facilitators into how best to approach the role plays, and participants could select which scenarios they want to focus on. As well as affording participants with opportunities to practice communication skills, and to use their knowledge of health issues from the modules and elsewhere, the workshops enabled participants to improve their knowledge of the organisation of health services (via discussion with the facilitators) and to see each other ‘in practice’, something PAs are rarely able to do. Handouts were provided that summarised the evidence on what makes for effective helpers, effective change talk, effective interviewing skills, plus a handout on adverse childhood experiences and trauma-informed practice. At the end of each workshop PAs were asked to complete a self-assessment of their perceived abilities in respect of ten communication skills covered in the workshop using a 10-point Likert scale. Examples of the items include: ‘I am able to use limited self-disclosure and humour where appropriate’. I can ask questions in the context of uncertainty, where my knowledge is limited. They were also asked to set themselves at least one SMART goal, and to consider what evidence of success would look like. They were asked to provide their line manager with a copy of their goals so that these could be discussed in supervision and expected to report on these at the follow-up group session. Copies of the Manual are available from the contact author. Changes in design Following a pause in the study due to the COVID-19 pandemic, the feasibility study was scheduled to commence in September 2022 and the three participating local authorities were expecting their staff to be trained in October 2022. Prior to pausing the study, all planned data collection had been agreed and, in February 2022, submitted to the CTU responsible for organising the online REDCap surveys and databases. The Bristol Trials Centre was unable to develop the REDCap surveys and database in time for this schedule, due to competing demands from other paused studies restarting during 2022, and increased demands from studies that had to move some of their activities to the online format. This meant that we were unable to start recruitment until December 2022, which was problematic as the local authorities advised us that December and early January were not optimal times to train PAs. In order to mitigate the delays, we agreed the following changes with the funder, with the support of the Trial Steering Committee (TSC): Deferring the recruitment of care leavers, to enable the REDCap data base for PAs to be prepared in a shorter time. We anticipated that we could still recruit Care leavers prior to the PAs finishing their training. We amended the eligibility criteria for recruiting care leavers, to open recruitment out to any care leaver. The original restrictions on eligibility criteria were designed primarily to manage expectations, and also because we thought it might be easier to detect any impact of the training. However, although local authorities had informed us otherwise, we initially struggled to recruit care leavers, particularly in one local authority. Broadening our recruitment strategy to include social media helped to address this. Shortening the planned follow-up periods by two weeks, so collecting data at baseline, 24 and 48 weeks post-randomisation, rather than 26 and 52 weeks. This was because, despite staggering the recruitment of personal advisors and care leavers, it took longer than anticipated to complete the training and, in particular, to schedule the Skills Workshops and final group meetings with the PI. In addition, we made the following changes: We dropped the PEPPI-10 ( 50 ) at the final follow up with care leavers, because they reported frustration at being asked what seemed to them to be ‘the same questions’ in the interviews, and in light of what interviewers perceived to be an evident ceiling effect. After several attempts, we abandoned the use of peer researchers to conduct the interviews with care leavers and took these ‘in house’. Essentially, it proved too difficult to arrange for those recruited as peer researchers to conduct interviews due to other commitments. In our proposal we had proposed some provisional progression criteria, but following discussion with the TSC it was agreed that these were inappropriate for this feasibility trial, which was neither part of a programme grant, nor the pilot for a pragmatic trial where such criteria would inform the internal stop/go decision. It was also recognised that it was likely that a great deal might change between the completion of this trial and any proposal to seek funding for a pragmatic trial. With the funder’s agreement, we therefore amended our focus to using the information gained in this trial to: Help clarify which aspects of the training are ‘essential’ and which are ‘useful’ (and whether this categorisation differs according to the pre-existing knowledge and experience of personal advisors), Determine how best to further develop the training so that it could, in principle, be ‘rolled out’ into practice, if a future trial suggested it was helpful to PAs in supporting care leavers with health issues, and Gather information on the methodological issues, such as our ability to recruit and retain care leavers, and the appropriateness of the measures we are using (e.g. acceptability and any ceiling effects) that might inform the number of sites and number of potential participants for a pragmatic trial. We learned early on that it would not be possible to access useful administrative data e.g. to identify eligible care leavers or use records in health passports or pathway plans. Despite budgeting for administrative support within the local authorities, we were told this would not be possible given the organisation of records. Measures used to assess the feasibility outcomes The approach adopted to establishing feasibility in respect of the primary and secondary objectives is set out in Table 2 : Feasibility outcomes and means of assessment2. Table 2 Feasibility outcomes and means of assessment. Objective OUTCOME How assessed PRIMARY 1 PA recruitment % per LA 2 PA retention % of those recruited per LA 3 CL recruitment Count of CLs randomised Target sample size reached 4 CL retention to 12 months % of those recruited 5 Masking of outcome assessors (interviews) Asking interviewers to record whether interviewee has an intervention or control PA – best guess if they don’t know (two-alternative forced choice) SECONDARY 6 Acceptability of data collection (burden and cost) % CLs completing surveys and interviews at each time point % of PAs completing surveys and interviews at each time point 7 Factors influencing training completion Interviews with PAs and CLs 8 Performance of outcome measures Acceptability – interviews with CLs Completeness, means, variability and distribution of scores 9 Acceptability of randomisation Interviews with PAs and CLs 10 Evidence of contamination across intervention and control arms Information from LAs regards staff movements + Interviews with PAs 11 Implementation fidelity and cost Monitoring of module completion by PAs PA Attendance at Skills Workshop Observation of Skills Workshops Cost of the time and resources required to set up and deliver the intervention 12 Estimate of the Intra-cluster Correlation Coefficient For the likely primary outcome measure, the ICC will be estimated with 95% confidence interval Adverse events and Harms These were defined as any unexpected or adverse event occurring in the conduct of interviews with care leavers i.e. as a direct result of the interview or concerns about the safety and wellbeing of care leavers that emerged within the interview. In accordance with an agreed protocol for dealing with harms or adverse events, with the care leaver’s knowledge, these were reported to the PI and to the relevant local authority and followed up until resolved. Feasibility study sample size Given the primary aims of this study were to ascertain the feasibility of those key procedural elements that would need to form part of a definitive cluster-randomised trial of the effectiveness of the training intervention, we judged that recruiting nine PA teams from three local authorities would be sufficient. We also judged that recruiting 20 CLs from each LA would provide the information required to judge the feasibility of a definitive trial. Masking It was not possible to mask participating PAs because of the nature of the intervention. CLs were not aware of the study status of their PA. Because the research team was responsible for organising and providing the training, it was not possible to mask the research team to the allocation status of PA teams. It was hoped that we could mask the peer researchers to the trial arms to which care leavers belonged but a consequence of taking the CL interviews ‘in house’ it was difficult to achieve 100% masking in relation to CL interviews. Analyses Data relevant to the feasibility of recruitment, treatment delivery, and participant retention will be presented in the CONSORT flowchart. Appropriate summary statistics will be presented by allocated group for each questionnaire measure completed by participants, to demonstrate the completion rate and sensitivity to effects of the intervention. For costing resource use, nationally applicable unit costs were sourced and are presented in Supplementary File 3 (Tables S1 and S2). All activities were costed at 2023/24 UK prices. For costing the health services resource use, subtotals for each of the cost categories were calculated and a total mean cost per care leaver presented by allocated group, along with the mean cost difference and bootstrapped 95% confidence intervals to understand the distribution of costs. The intra-cluster correlation coefficient will be estimated for the potential primary outcome(s) of the definitive trial using a variance components model and presented with its 95% confidence interval. Qualitative data were analysed using Framework Analysis. Results Participant flow Figure 1 summarises the numbers of both PAs and CLs at each stage of the trial. The dip in data collection from care leavers coincides with the difficulties encountered in organising peer researchers to conduct the follow-up interviews at this time. We recruited 63 of the 76 eligible PAs working in the three local authorities. Of those who consented, one later withdrew from the study. Figure 1: CONSORT flowchart PLACE FIGURE 1 HERE Characteristics of participants Table 3 provides an overview of the characteristics of participating personal advisors. Participating PAs were typically female, full-time, and had been in the job for about two years. PAs in each arm were broadly comparable in terms of gender and caseloads, with no obvious imbalance in terms of years of experience: compared with those in the control group, rather more PAs in the experimental arm had only two years or less experience (67% v 58%) and fewer PAs with three years or more (33% v 53%) but numbers are small. Not evident from Table 3 is the heterogeneity of career backgrounds of the sample as a whole, which ranged from someone with years of experience as a head teacher to PAs with very limited prior experience in working with young people. Table 3 Characteristics of personal advisors and caseloads by allocated groups Group allocation Intervention (n = 39) Comparison (n = 24) Completed baseline 37 21 Number female (%) 29 (78%) 15 (71%) Time as a personal advisor: Number 5 years (%) 7 (19%) 5 (24%) Number full-time (%) 28 (76%) 13 (62%) Mean caseload (SD*) 18 (3.9) 17 (4.3) Mean new cases in past year (SD*) 10 (7.8) 9 (7.1) Cases met before they left care ^ None 3 (8%) 4 (19%) Some 15 (41%) 7 (33%) Most 15 (41%) 8 (38%) All 4 (11%) 2 (10%) *SD = Standard Deviation ^ Refers to the number of care leavers with whom PAs started work before the former left care. Care leavers Table 4 summarises the characteristics of the CLs who took part in the study. Again, these were typically female, white and with a mean age of 19 years. Just over half were not in education, employment, or training. At follow-up, 20% of the CLs in the intervention group (9/46) saw a change in household composition and 26% (12/46) saw a change in accommodation type. Figures for those in the comparison group were 38% (9/24) and 25% (6/24) respectively. Further details on recruitment and participation can be found in Supplementary File 4 (Tables S1 and S2). Table 4 Care leaver characteristics by allocated group Intervention (n = 46) Comparison (n = 25) Mean age in years (SD), N 19 (1.3), 46 19 (1.6), 24 Number of females / N (%) 30 / 44 (68%) 14 / 24 (58%) Number with gender identity same as birth sex / N (%) 38 / 43 (88%) 22 / 23 (96%) Ethnic group : Number White (%) Number Mixed or multiple (%) Number Asian or Asian British (%) Number Black or Black British (%) 46 responding 33 (72%) 5 (11%) 5 (11%) 3 (7%) 24 responding 21 (88%) 2 (8%) 0 1 (4%) Current occupation : Number in education (%) Number in training / employment (%) Number not in education, training or employment (%) 46 responding 5 (11%) 14 (30%) 27 (59%) 24 responding 2 (8%) 8 (33%) 14 (58%) Number reporting no qualifications / N (%) 8 / 46 (17%) 6 / 25 (24%) Household : Number living with non-family adults in house-share (%) Number living with partner or family (%) Number living alone (%) Number living with partner & children (%) Number living with children only (%) 43 responding 11 (26%) 6 (14%) 21 (49%) 1 (2%) 4 (9%) 24 responding 7 (29%) 4 (17%) 8 (33%) 3 (13%) 2 (8%) Type of accommodation : Number in family home (%) Number In supported lodgings (%) Number in ordinary lodgings (%) Number with no fixed abode (%) Number living with former foster carers (%) Number living in other accommodation (%) 45 responding 4 (9%) 9 (20%) 22 (49%) 5 (11%) 2 (4%) 3 (7%) 24 responding 2 (8%) 7 (29%) 13 (54%) 0 1 (4%) 1 (4%) Results for the feasibility outcomes Details of the data collected from PAs and CLs at baseline and follow up are presented in Supplementary File 4. No unintended effects or significant harms were reported or identified. Primary Outcomes 1. Recruitment Personal advisors Whilst PAs were invited to participate in the study (i.e. providing data) their employers expected them to complete the training irrespective of their participation in the study. Of the 76 eligible PAs, 63 were recruited to the study (83%). Four members of the participating teams had specialist support roles e.g. housing support and were not eligible to participate in the study. They were not excluded from the training. Care leavers CLs were recruited by the study team from both PA who participated in the study (n = 35) and those who did not (n = 5). Recruitment of care leavers improved with a broadening of recruitment avenues, including research staff attending drop-ins and use of social media. No CLs were recruited from the caseloads of the remaining 28 PAs who took part in the study (Table S1 , Supplementary Materials). 2. Retention and completion of measures under consideration for a future trial One PA withdrew from the study at module completion stage. Personal advisors . Of the 63 PAs who consented to participate in the study, 58 completed the baseline pre-training survey (92%), 32 completed the first follow-up interview and 35 (56%) the final follow-up interview. Twenty-eight of the 39 PAs in the intervention arm completed the post-training survey (72%). Care leavers Of the 71 CLs who consented to participate in the study, three withdrew in the course of the study, for personal reasons (two from the intervention arm and one from the control arm). Masking of outcome assessors (interviews) Personal Advisors In the event, interviewers were not masked to the allocation status of PAs because follow-up interview schedules for intervention PAs included questions about the impact of the training on their practice, and – at baseline - interviews with those in the control group included questions about their views on their allocation to that arm of the trial. Care leavers With the exception of the senior researcher employed on the study, it was clear that masking interviewers to the allocation status of CLs was feasible. De facto, masking was not 100% in this study because it did not prove possible to use peer researchers. Instead, we recruited two post-doctoral fieldworkers to conduct around one half of the interviews. The senior researcher was not masked to status because she was responsible for allocating interviews. The other researchers were unaware of the status of those they interviewed. Secondary Outcomes 4. Acceptability of data collection (burden and cost) Personal Advisors All but 5 of the 63 PAs recruited completed the baseline questionnaire (92%), but this dropped to 32 (51%) and 35 (56%) at first and second follow-up survey respectively. Of the 39 PAs in the intervention group, 28 (72%) also completed the post-training survey. At baseline, the majority of PAs said they were either ‘very pleased’ or had ‘no particular feelings’ about taking part in the study, and all but 11 said they were happy with the proposed data collections planned in the following 12 months. The remaining PAs said they would rather not have to speak to a researcher on two occasions in the next 12 months but didn’t mind doing so. At the end of the study, those intervention PAs who gave general comments about trial participation reported no concerns about the data collection tools or number of contacts, other than about the timing and communication regarding some of the study events (two PAs in LA 2). Three intervention PAs mentioned finding participation in the study worthwhile, one who hadn’t completed the training due to absence welcomed the opportunity to feedback on health issues for CLs in the interview. "I think I was just glad of the experience and I've taken a lot from it and I am very thankful to have been a part of it." (LA 3 Participant 5 - intervention) Of the six PAs in the control group, all found the study requests and contacts from the study team to be reasonable. Care leavers At the first follow-up 37 CLs were interviewed (52%) and at the second follow-up 49 were interviewed (69%). Table 5 summarises the completion of the bi-monthly Health Service Use questions and interviews conducted at the two follow-ups. The 6- and 12-months collection of Health Service Use data was included in the interviews (mostly conducted by telephone); those at 2, 4, 8, and 10 were collected by telephone. In respect of the collection of health service use data, we received information from 41 at 2 months follow-up (69%) 33 at four months, 24 at 8 months and 39 at 10 months (55%). Given this population is generally considered ‘hard to reach’ the completion rates suggest that the data burden was acceptable. The outcome measures used were administered by research staff. Table 5 Completion rates of data collection from Care Leavers Baseline HSU 2 months HSU 4 months Follow-up 24 weeks 1 HSU 8 months HSU 10-months Follow-up 48 weeks 1 71 47 (66%) 33 (47%) 42 (59%) 34 (48%) 39 (55%) 52 (73%) Intervention 46 28 20 26 19 24 32 Control 25 19 13 16 15 15 20 1 Includes HSU questions Completeness of the health service use questionnaire suggested that it was acceptable to care leavers (Supplementary File 3, Table S3 ). Use of primary care services and community care services were well reported in that service use could be costed appropriately. The categories of secondary care services and medication use had the highest proportion of incomplete data (16.9% and 13.4%, respectively), indicating that greater care may be needed in collecting data for these items, or alternative sources identified such as electronic healthcare records. The mean costs per CL by category of health service use are presented in the tables in Supplementary File 3, along with the mean cost difference and bootstrapped 95% confidence intervals. There were no differences observed between the two groups on total mean cost per CL (mean cost difference: -£211.00; bootstrapped 95% CI: -£1111.99 to £617.99), nor by cost category. Cost drivers were the secondary care service use, which included out of hours services, 999/111 calls, ambulance services, emergency department attendances, hospital admissions, and hospital outpatient services. Thus, reiterating the need for greater care to be taken during data collection to elicit valid responses in a full trial. Community care service use was also a cost driver for both groups, which was indicative of the inclusion of costs associated with the personal advisor, as well as community mental health services. 5. Completion of training The majority of PAs appear to have engaged with between 5 and 6 modules, but information on the extent to which PAs fully engaged with the six modules is limited for two reasons. First, the platform used to host the modules only allowed us to identify which modules individual PAs had opened. Second, we know that in the LA that set aside one day for the two intervention teams to complete the modules together, the arrangement did not work well (see below). 6. Factors influence completion of training Views on the training were gathered at the second webinar and in interviews with a subsample of seventeen PAs. They also emerged at the Skills workshops. Mode of delivery and time required Managers in two LAs agreed to make time available within the working week for PAs to complete the training over a period of 2–3 weeks. This was what was intended, but the third LA the Service Manager made the decision to allocate one protected day for PAs to complete all the modules, in order to support study timings and avoid the Christmas holidays. Neither of the PAs interviewed from this LA said this was problematic, but in feedback at the Skills workshop there were strong feelings that it was too intensive to complete the modules in one day and that completing the modules as a group was impractical. This is not surprising as the modules were not designed to be viewed in a group, and we learned that some PAs drifted away and not all modules were covered in the designated day. This made it difficult to ascertain how many modules had been viewed by how many PAs in this LA. Views were generally mixed about the provision of the training online. Some liked the flexibility afforded by online modules, in respect of when they could watch them and at what pace. Others found the online delivery difficult. The quotes below illustrate the two opposing views about training timespan and the perceived benefits of interaction and reflection time: "So just to have it a bit in a more of a bulk training maybe over a day or two rather than have it spread out how it was. And maybe how it was like the online and the face to face, I think that that worked really, really well because not a lot of us have time to go to these sessions, but we could do them in our own time. But yeah, I do think that we should have been able to dedicate two whole days to be able to do everything in one and make it more of an interactive workshop together, all of us PAs " (LA 2, participant 50) Q: “I think the timing of it wasn’t great, because it was Christmas and it was crazy busy, and that I think put an additional pressure. So I feel that, as I’m sure my colleagues felt, we kind of felt we had to rush through it. Whereas I think, given more time and spread out over a longer period of time, so whether that be monthly or fortnightly, one of the modules, I think it would be a bit more powerful, you’d be able to take more in and reflect on it more. Whereas we were trying to squish everything into a day.” ( LA 2 participant 64) The evidence from the platform used to host the modules (NIHR LEARN) and from interviews and other discussions with PAs suggested that protected time to complete them was difficult to secure. There was a noticeable difference across the three local authorities in the interest and support from senior management. In one local authority the senior manager responsible was very active in not only reminding staff of the training and the study requirements, but in facilitating their completion of these. In another, the senior staff delegated responsibility for the study to the team leader of one of the intervention team, who did very little to support staff with either. The senior manager in the third was proactive, but over-stretched, and the local authority was facing some organisational challenges. In general, PAs in all three local authorities felt the training was ‘over-and-above’ their already busy workloads, even in the agency with most management support. Perceptions of the Content The content of the training was generally well received. Of the 11 PAs who commented specifically on the usefulness of the modules five said they were all useful, with one PA pointing out that it was especially useful to them as it was their first year as a PA and another highlighting the structure of the modules with summary points as being very good. Unsurprisingly, different PAs identified different modules as being particularly useful to them, ranging from dental health (5 PAs), health service structure (3 PAs), through sexual health and relationships, mental health, drugs and trauma, and barriers to care leavers accessing health services all singled out by individual PAs. Some PAs selected more than one module topic. The general relevance of the modules to their work was confirmed in the webinars, and the few PAs who considered certain modules being less useful cited their existing knowledge and experiences as reasons for this. In one LA, PAs had already received training on trauma, so found this less useful. “…they're all useful in some way because …. you know when we first start, we have like during our induction period, we obviously focused on a lot of areas of people's lives such as like housing and sort of like relationships and work and learning, things like that. But we don't necessarily have anything that incorporates sort of health." (LA 2 Participant 54) “But I think more the point that hit home with myself is that I wouldn't have thought twice before, oh, do you see a dentist regularly? Are you going to an optician regularly?” (LA 3 Participant 6) “I came at it from someone who has been doing this kind of work for nearly ten years and it was a bit of a recap and actually a lot of it was quite basic stuff that yeah, we kind of knew anyway.” (LA 1 Participant 42) The skills workshops provided participants with an opportunity to discuss the research evidence on the correlates of effective helping relationships, and to practice core skills. They were overwhelmingly considered to be positive. The communication skills were appreciated, along with the chance to learn from colleagues. PAs welcomed the input of health professionals to answer questions about the health service and how to use them effectively. “Use of key words, being older my language perhaps is not up to date with current trends in what words to use, so that was helpful.” (LA 1 Participant 28) " the skills workshop … tied up all of the online resources, and it was nice to be in part of a group to be able to talk about everybody's thoughts and opinions on those online sessions as well. It was useful that the person hosting the skills was, I believe she said she was a psychologist, I believe, so I think that was really interesting because it showed us like the reasoning behind behaviours and things, and it just ties up everything really quite well" (LA 2 Participant 50) There was general agreement that the training would be useful for those new to the PA role. Discussions at webinars and the skills workshops suggested that those who felt they knew they content were not always as well-informed as their responses suggested. For example, in the Local Authority whose PAs most often asserted that they were already familiar with health issues it was evident that there was limited understanding of the longer-term impact of trauma. 7. Acceptability of randomisation Randomisation was viewed as acceptable by all three local authorities, and by the PAs who attended the first webinar Some PAs and managers were variously disappointed or relieved at being allocated to the control arm. In one local authority, two of the control PAs who were interviewed said they would have found it hard to fit additional things into their schedules, but in another local authority, four PAs said they were disappointed to be in the control as it meant they missed out on training they thought would benefit care leavers. One of these PAs said they ignored information from the study team because of this. For two other PAs in this LA, they were conflicted, feeling disappointed at not receiving the training but also happy about not having extra tasks to do too. “Yeah. I was a little bit disappointed, actually, because I always welcome any training, or any new learning. So, I was a little bit confused, I’d say, ‘What does that mean? What am I going to be doing, then?’ And I was a bit like, ‘Oh. Why didn’t we get picked?” ( LA 3 Participant 21) 'I think initially I was annoyed that I was missing out. But then, straight after that, I was, kind of, relieved, because I thought, ‘Where am I going to find the time to do it?’ So, it was, kind of, a bit mixed, really.” ( LA 3, participant 16) “We're so busy we haven't had time to go, ‘Were you not? Are you not going to do that?’ There's so many other things going on for us, that this is, no offence, but this isn't like a big thing that we're dealing with, so it often gets sort of by the wayside just because we're like, ‘Oh, I didn't get selected, okay, crack on” ( LA 1 participant 39) 8. Evidence of contamination across arms The control PAs interviewed were asked about contact with intervention team colleagues where the LIFT study may have been discussed; none was reported. A couple of PAs mentioned that they spent limited time in the office post pandemic and in two of the local authorities, teams were based in different locations so there would have been limited opportunities for contamination. One PA from the LA where teams were co-located moved from an intervention team to the control team after the training had been completed. The two control PAs interviewed from that local authority reported no discussion about the study with this PA, and one said, ‘There’s been no cross-fertilisation’! 9. Implementation fidelity and intervention cost All workshops (which were observed) covered the programme as set out in the manual. Whilst all participating intervention PAs engaged with the modules, we cannot be confident that all PAs completed all modules. At the end of the Skills Workshop intervention PAs were asked to share their SMART goals with their line managers in order to embed a focus on health within routine practice. Those PAs who attended the final session reported that their goals were generally achieved but we do not have information on the success or failure of PAs who did not attend this final session. The cost of the training programme for PAs is presented in Supplementary File 3 Table S4 . The greatest category requiring investment by LAs would be the protected time for staff to complete the training. 10. Performance of candidate outcome measures and Estimate of the Intra-Cluster Correlation Coefficient Table 6 presents summary statistics for the standardised measures, with the baselines presented for those participants who at least partially completed one of the main follow-up assessments. The PEPPI10 was discontinued after the first follow-up to reduce participant burden and due to overlap with the Pearlin Mastery Scale. All CLS were invited to complete the Pearlin Mastery Scale at the final follow-up, with 50/71 (70%) doing so. The modest number of CLs participating in this feasibility study prevents any conclusions being drawn from changes in the mean values over time in the two groups. Furthermore, the modest number of PA teams resulted in very imprecise estimates of the ICCs (see Supplementary File 4, Table S16c). Table 6 Completion of interviews and standardised measures Intervention (46 CLs) Comparison (25 CLs) Mean (SD), N* Mean (SD), N* Perceived Efficacy in Patient-Physician Interactions Questionnaires Baseline – responding to follow-up 35.3 (12.0), 36 38.5 (10.6), 21 First follow-up 39.1 (10.5), 21 36.9 (11.9), 16 Pearlin Mastery Scale Baseline – responding to follow-up 13.1 (3.5), 37 13.8 (3.2), 22 First follow-up 13.8 (2.6), 23 13.7 (4.3), 16 Final follow-up 13.6 (3.8), 31 14.1 (3.7), 19 Recovering Quality of Life (ReQoL-10) Baseline – responding to follow-up 25.3 (7.9), 23 27.5 (3.5), 10 First follow-up 25.5 (6.9), 15 29.4 (8.2), 8 Final follow-up 27.2 (9.3), 22 28.4 (10.1), 9 Recovering Quality of Life (ReQoL-20) Baseline – responding to follow-up 52.3 (15.3), 14 53.7 (5.7), 4 First follow-up 51.3 (14.1), 10 56.7 (14.8), 3 Final follow-up 58.1 (12.6), 13 63.5 (16.0), 4 *N = number responding, SD = standard deviation DISCUSSION This feasibility study suggests that the training intervention developed for PAs was broadly acceptable, and that it is feasible to recruit and retain both PAs and CLs in a randomised controlled trial within children’s social care. A large majority (83%) of eligible PAs agreed to participate in the trial (63 out of 76), and we recruited 71 CLs, eleven more than our target. At 73% at 48 weeks, the retention of CLs was good, indicating that the key procedural elements needed to form part of an experimental evaluation of the training’s effectiveness are feasible. Recruitment of CLs by the study team, rather than via PAs, would help ensure a representative sample of CLs, and preliminary work with team leaders might help to embed learning in practice. Because it proved not to be feasible to deploy the peer researchers in the study, it was not possible to blind all outcome assessors because we did not have alternate resources. However, the study indicates that blinding of outcome assessors is, in principle, feasible. Whilst some of the questions included in the final interviews with PAs were ‘arm-specific’, these would not form part of a pragmatic trial. The data suggest a potential source of selection bias, in that from a mean caseload of 18, we recruited only one or two CLs from most PAs to the study, and none from close to one half. In relation to our secondary objectives, randomisation presented no problems and the feedback gathered from PAs and CLs suggest that the data burden was acceptable and importantly, that we were not asking too much of CLs. There was no evidence of contamination between the two arms of the trial. The key problem to emerge related to the outcome measures chosen and their performance. It is very difficult to identify one outcome measure that can adequately capture the potentially diverse range of effects of the intervention across a large group of CLs with very different health issues and yet be sensitive to the specific effect in each individual. A core outcome set for CLs would be helpful, but our experience suggests it would be challenging to establish. Whilst the questions to CLs were acceptable, we dropped one at first follow-up because of an apparent ceiling effect and to minimise some apparent overlap between questions on the PEPPI-10 and our open ended questions about their relationships with their personal advisors. The remaining measures appeared not to be sufficiently sensitive to discriminate between the two groups. Limitations As is frequently the case for a feasibility study for a cluster RCT, the key limitation was the limited number of sites and of PA teams that could be involved. Consequently our estimates of the ICCs were not usefully precise. Generalisability Whilst participating sites are not typical of all LAs (no London boroughs or metropolitan councils, or rural sites), the baseline data from this study are likely to be generalisable to other areas. The three LAs who participated in this study included two large counties, and one large city council. All had different organisational structures, which required flexibility in planning the delivery of the training. In 2022, when recruitment commenced, One was in contact with 166 care leavers aged 17-18 and 332 care leavers aged 19-21 (99% and 91% respectively). In another, the numbers were 82 and 252 (93% and 97%) and in the third they were 129 and 305 (100% and 97%). Nationally in that year, LAs were in touch with 94% of care leavers aged 17-18 and 92% of those aged 19-21. The Principal Investigator had previously worked with one LA on another trial, but the relationships with the other two were new, and none of the teams involved had previously participated in a randomised trial. The skills workshops served to highlight both the very challenging nature of the personal advisor role, and the limited knowledge that most have of ‘what works’ in engaging young people in sensitive discussions in general, and health issues in particular. Typical skills included asking open ended questions, asking specifically about health issues or concerns that personal advisors might have about a particular young people, how to convey key relationships skills such as empathy, warmth and genuineness, and when and how to use skills such as humour or limited self-disclosure.(55) Although the three sites were located in the South West and the East Midlands, in respect of the training intervention, the training that PAs were most likely to have received outside of the trial was training in trauma-informed practice, reflecting a larger trend to make such training available to the children’s social care workforce, though evidence of a good understanding of the impact of trauma was not very evident. Broader training on health issues is not available. Interpretation The CLs we recruited were mainly female, and mainly white British, despite there being sizeable populations of minoritised ethnic groups in two of the three local authorities. Data on the ethnicity of CLs is difficult to obtain, but in Bristol, for example, 10% of CLs were unaccompanied asylum-seeking young people, but the project only recruited one. In Nottinghamshire in 2024, 9.9% of care leavers aged 18-21 identified as ‘mixed race’, 1.4% as Black and 2.4% as Asian, but the study recruited very few minoritised participants, In respect of gender and ethnicity the CLs we recruited were not representative of CLs nationally. Recruitment via social media and in person sessions (with researchers) attracted more interest from a wider range of care leavers in terms of gender and ethnicity, and such approaches are likely to enhance recruitment in future trials. Recruitment strategies that enabled details of the study to be circulated directly to care leavers would also improve recruitment, as our reliance on professionals within the agencies was somewhat problematic, particularly in the LA lacking strong leadership for the study. Recruiting CLs from the caseloads of all participating PAs would assist in securing evidence of the impact of training in a future, pragmatic trial, or in any trial interested in the impact of changing staff knowledge, skills or practice methods. In respect of data collection, we experienced few problems in maintaining contact with care leavers. The ‘dip’ in response rate at the first follow-up was largely attributable to the realities of seeking to use peer-researchers. We recruited and trained two groups of peer researchers to conduct the follow up interviews, and to text care leavers to gather the two-monthly Health Service Use data. Implementation proved problematic, with peer researchers often unable to conduct interviews, most often for logistical reasons e.g. our requests clashing with essay deadlines for those studying in higher education, but sometimes for personal reasons e.g. poor mental health or family difficulties. Our reflection is that it is not feasible to expect peer researchers (or any other researchers) to work on what is, effectively, a ‘zero hours contract’. This view was endorsed by the TSC, whose members included those with many years’ experience of working with CLs and those in care. They recognised the excellent input of care-experienced young adults on the Advisory Committee throughout the study, but agreed with the research team that seeking to recruit peer researchers for what is, effectively, an unpredictable schedule of interviews on such a basis is not feasible, however well supported and trained they are (and were) by CORAM staff and those on the study team. Recruiting researchers with care experience as part of the core team or conducting the interviews ‘in house’ is more feasible. The latter worked well, as evidence by the upturn in response rates once the team took this decision. The completion of follow-up interviews by PAs was reasonable in two of the three LAs at 58% and 63%, particularly as a number of staff in these authorities had extended periods of leave of three months (4 and 3 respectively). In these authorities, there was active promotion and management of the training and compliance with the study by a senior manager. Such support and leadership were not available in the third and we believe this was a major factor in the poorer participation in follow-up interviews by PAs (26%) and in generally more negative attitudes towards the training provided. The qualitative data from PAs confirmed the relevance of the content of the training modules and the skills workshop. Those who felt they were familiar with some of the content said it was a ‘good refresher’, and some of the content addressed issues that had received little attention, such as oral health, the importance of embedding ‘health in every contact’ and of asking open ended questions. Implications for progression We discussed the results with our TSC and with a group of care-experienced young people. The TSC considered the trial to be a success in respect of the study aims and suggested that a pragmatic trial was feasible, with the caveat of the need to identify an adequate outcome measure or measures. The study highlighted minor changes to the methods that would increase the likelihood of a successful future trial, such as ensuring the involvement of senior social care leadership, using social media and recruitment methods that enabled the team to contact care leavers more directly, though this might have cost implications. The study also pointed to minor changes that might facilitate more effective engagement with the content of the modules, such as shortening some of the longer modules and adding questionnaires at the end of each module to ensure those working through them adequately understood the materials. The poor follow-up questionnaire completion by PAs, along with some baseline responses missing, may indicate, respectively, ‘survey fatigue’ within the participating local authorities or ambivalence by some staff. Some members of the TSC were unconvinced of the appropriateness of pursuing a future trial for a range of reasons. The qualitative feedback from study participants and the data gathered from the measures provided no indication that the training had benefited those in the intervention arm compared with those in the control arm. Others considered that the evident heterogeneity amongst PAs in their levels of knowledge and skills, combined with a general lack of health literacy amongst many merited consideration being given to making the training available in the absence of further evaluation. Conclusions Taken together, this study demonstrates the feasibility of conducting a randomised controlled trial in children’s social care within the UK. An evaluation of the LIFT intervention specifically would need an outcome measure able to capture the diverse potential benefits across the community of CLs, and the participation of those PAs and CLs with the greatest potential to benefit. A future trial would also need to consider implementation costs (including pre-implementation and planning, adaptation, intervention and sustainment) in order to understand the budget impact. Building on the intervention costs and valuation of resource consequences reported herein, further economic methods could consider a policy cost-effectiveness approach or a value of information and value of implementation approach, dependent on local decision-makers’ needs. The TSC raised broader concerns which need to be considered alongside the results of this study when deciding whether to proceed to a full trial evaluation of the LIFT intervention. Declarations Acknowledgements The study team would like to convey our appreciation to all those Personal Advisors and Care Leavers who participated in the study, and to those in the local authorities who showed leadership in facilitating the study, who encouraged their staff to participate and made time available for them to take part in the study and, for those in the intervention group, the training. Experts by experience We would like to express our gratitude to the care experienced consultant advisors who helped us both to develop the training and to deliver the study. Particular thanks to Peer Advisors Thuy-Ly Chambers, Kiri Scamp, and Sarah Beth Harper. Local authorities Gloucestershire County Council, Bristol City Council and Nottinghamshire County Council. Trial Steering Committee Dr Kristin Liabo (Chair) University of Exeter; Professor Mike Clarke, Queens University, Belfast; Professor Helen Roberts, Institute of Child Health, University College, London; Dame Annie Hudson, Chair of the Child Safeguarding Practice Review Panel; Dr Jane Schulte, Formerly Medical Advisor, CCS Adoption, Christa Laird, Formerly Social worker and Training and Development Manager, Oxfordshire Social Services. Trial Management Group Shelley Caldwell, North Somerset Council; Linda Briheim, Coram Voice; Thuy Lee-Chambers, Coram Voice; Sarah Beth Harber, Coram Voice; Kiri Scamp, Coram Voice; Jenny Humphreys, Coram Voice; Shelley Reed, Coram Voice), Julie Selwyn, Rees Centre, University of Oxford Authors’ contributions GM designed and oversaw the study, with input from PL, JT, CM and FL. GM, JH and LC designed and carried out the process evaluation, with advice from PL, and FL designed and led the health economics activities. JT, JH and LC managed the study. 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Supplementary Files LIFTPilotandFeasibilityTrialsChecklist.doc SupplementaryFile1.docx Supplementary File 1: Logic Model and Theory of Change SupplementaryFile2.docx Supplementary File 2: Content of Online Modules SupplementaryFile3R.docx Supplementary File 3: Health Economics Components SupplementaryFile4R.docx Supplementary File 4: Tables of Findings Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 15 Jan, 2026 Editor assigned by journal 24 Nov, 2025 First submitted to journal 20 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":35514,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/9b97847784de43dbb1881ab6.png"},{"id":101397781,"identity":"b8273f87-71af-468a-8323-b96d55e1da4f","added_by":"auto","created_at":"2026-01-29 09:36:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1405209,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/834a10b4-6594-4c51-8a0c-ab4d751892b1.pdf"},{"id":100796554,"identity":"129a4295-30e5-4bd2-ad66-1c637d3ab55c","added_by":"auto","created_at":"2026-01-21 13:44:09","extension":"doc","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":232960,"visible":true,"origin":"","legend":"","description":"","filename":"LIFTPilotandFeasibilityTrialsChecklist.doc","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/2f9f9054cd66bede5f986d7a.doc"},{"id":100796658,"identity":"583b1ab5-9fb5-45d6-95f9-7edfae43e5b0","added_by":"auto","created_at":"2026-01-21 13:44:49","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":326870,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary File 1: Logic Model and Theory of Change\u003c/p\u003e","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/bf5a331cc8f48ee1c47ea788.docx"},{"id":100749532,"identity":"a39aa4e7-91a0-4b69-b120-801cd366957c","added_by":"auto","created_at":"2026-01-21 04:22:07","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":20651,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary File 2: Content of Online Modules\u003c/p\u003e","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/c8a8211cb6ae395eea99e875.docx"},{"id":100749545,"identity":"23334bef-d36a-4da5-868e-f5c19633d294","added_by":"auto","created_at":"2026-01-21 04:22:08","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":47207,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary File 3: Health Economics Components\u003c/p\u003e","description":"","filename":"SupplementaryFile3R.docx","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/482523a27faeb460f8307ad9.docx"},{"id":100796524,"identity":"20dfb2aa-4080-41a1-9219-0a40bb554876","added_by":"auto","created_at":"2026-01-21 13:43:55","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":145025,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary File 4: Tables of Findings\u003c/p\u003e","description":"","filename":"SupplementaryFile4R.docx","url":"https://assets-eu.researchsquare.com/files/rs-8000798/v1/1a68a7ef8fa640e8b375a42a.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eImproving Health Outcomes for Care Leavers: the Life in Transition (LIFT) cluster-randomised feasibility trial\u003c/p\u003e","fulltext":[{"header":"Key messages regarding feasibility","content":"\u003cul\u003e\n \u003cli\u003eWhat uncertainties existed regarding the feasibility?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eStaff known as Personal Advisors (PAs) have a statutory duty to support care leavers in their transition from care to independent living. Such support includes care leavers’ health and wellbeing, including their emotional health. Evidence from care leavers suggests that Personal Advisors attend less to their health issues than to other areas, such as housing, education and employment, and a survey of local authorities in England and Northern Ireland indicated that personal advisors receive little, if any, training in how to support care leavers that would maximise their health outcomes. We wanted to know whether a brief training programme comprising six online modules and a one-day in-person skills training provided by health professionals, could improve the health support provided to care leavers by PAs.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWhat are the key feasibility findings?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWe had no difficulty recruiting local authorities, personal advisors or care leavers to participate in a cluster randomised trial. Almost all PAs agreed to participate and we recruited more care leavers than planned. Retention was also good, and it is in principle possible to mask outcome assessors, although limited resources and exploration of the experience of participating in the trial meant this was not entirely possible in this feasibility trial. Feedback from PAs suggests the approach to training was acceptable, although some said they were already familiar with the content of some modules, and some said it was difficult to prioritise the online modules over more pressing practice matters. Despite an agreement from managers to allocated protected time for the training, this was not achieved in every agency. The in-person skills sessions were valued for the focus on how to raise and address health issues, and the opportunity to learn from health professionals and from one another. The key problem to emerge related to the outcome measures chosen and their performance. It proved difficult to identify one measure that could capture the diverse range of effects that the intervention might have across a large group of care leavers, and that were sensitive to the specific effect in each individual.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eWhat are the implications of the feasibility findings for the design of the main study?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe study indicates that it is possible to undertake randomised controlled trials in children’s social care. The intervention, whilst acceptable to participants, might be more accessible if each module was shorter. Given the return to face-to-face training in many areas, it might be sensible to consider providing the module content in in-person workshops. Whether online or in-person, it would be helpful to incorporate some before-and-after measures of understanding in order to better monitor the delivery and impact of the training. Ensuring each PA was represented by at least one of their care leavers participating in the study would ensure that outcome measures completed by the care leavers captured the effect of the intervention on the whole PA team. Recruitment of care leavers by the study team, rather than via PAs, would help ensure a representative sample of care leavers, and preliminary work with team leaders might help to embed learning in practice. A main trial would need to identify measures that were sufficiently sensitive to identify improvement in care leavers’ general well-being or – given the long-term follow-up required to achieve this - to more robustly identify improvements in knowledge and practice amongst PAs.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eInequalities in health amongst care-experienced children and young people span all aspects of health. Despite improvements in recent years, and recognising the difficulties in comparisons with the general population, looked after children remain less likely to have received all routine immunizations, (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e) with lowest rates amongst older looked-after children and unaccompanied asylum-seeking children. (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e) They are at greater risk of early sexual initiation (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e) and of sexual exploitation, (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e) more likely to become pregnant and to become parents at an early age. (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) Care experienced young women are more likely to smoke during pregnancy, to have symptoms of depression and deliver a low birthweight baby.(\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e) They may be at increased risk for pre-term birth (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e) and to have an elevated risk of their own children being taken into care, (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e) with a significant number experiencing recurrent care proceedings. (\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e) A systematic review of studies estimating the prevalence of mental health disorders among children and young people in care in the UK demonstrated that estimates vary considerably (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e) but there is general agreement that the mental health of children in care is poorer than that of comparable peers (e.g. 17). Many children enter care with existing mental health problems, often associated with trauma (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e) and the Departments of Education and Health estimate that almost a half of LACYP have a diagnosable mental health disorder.(\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eIn 2021, researchers compared the inequalities of health and social functioning between adults who had experienced time in care (the \u0026lsquo;non-parental care group\u0026rsquo;) and a group cared for solely by their parents (the \u0026lsquo;parental care group\u0026rsquo;). Using data collected between 1971 and 2011 the team looked at the impact of care experience and placement type on a range of outcomes, including self-rated health, limiting long-standing illness, all-cause mortality and cause of death. Adults with care experience reported poorer health and more limiting long-standing illness than those without, were more likely to die form \u0026lsquo;unnatural causes, such as suicide, drug overdoses, alcoholism, car accidents and assaults.(\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e) They estimated that the risk of premature death for care experienced adults was 62% higher than for those in parental care. This only dropped to 43% when controlling for differences in socio-economic status.\u003c/p\u003e\n\u003cp\u003eThe UK National Service Framework for Children, Young People and Maternity Services recognises children and young people in care as a particularly vulnerable group.(\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) Various policy initiatives have sought to improve their physical, sexual and mental health. The introduction of the looked-after children (LAC) \u0026lsquo;named nurse\u0026rsquo; represented a significant investment in promoting the health of children whilst in care, but that support can no longer be accessed when young people leave care.\u003c/p\u003e\n\u003cp\u003eCare leavers\u003c/p\u003e\n\u003cp\u003eEvery year, some 10,000 children aged 16\u0026ndash;18 years leave local authority (LA) care in England (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) and many start to lead independent lives. Most make the transition against a background of significant adversity and trauma, having been removed from the care of their parents due to abuse and neglect. (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) Transition to adult services and responsibility for their own health care takes place much earlier than it does for most young people, and for those in care it can happen very suddenly. (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e) Those with mental health needs are likely to find themselves without support at a time they need it most, and many care leavers face loneliness and isolation. In this arrangement of service provision, young people are faced with a system that is \u0026lsquo;weakest where it needs to be strongest\u0026rsquo;.(\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e) A health survey completed by 418 care leavers found that 44% stated they regularly drank alcohol to excess and 29% had self-harmed. (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) They felt that their health needs were not understood and they had found it difficult to access adult services. Care leavers are more likely than those who have not been in care to engage in risky behaviours, such as smoking, substance use and misuse, and unprotected sex. They are over-represented amongst the homeless, (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) among young women who become teenage parents,(\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) those who self-harm, (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e) and those involved with the criminal justice system.(\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) The most common theme reported in all studies of care leavers\u0026rsquo; views are feelings of isolation and loneliness.\u003c/p\u003e\n\u003cp\u003eThere are also significant societal costs. For example, mothers who are CLs are at increased risk of parenting problems and unstable housing arrangements,(\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e) and their children are more likely to be taken into care,(\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e) leading some women to avoid involvement with services. (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e) Using the costs to young people of not being in education, employment and training (NEET), the NAO estimated lifetime cost of the 2015 cohort of 19-year old care leavers to be around \u0026pound;240\u0026nbsp;million - \u0026pound;150\u0026nbsp;million more than if they had the same NEET rate as 19 year old young people who had not been in care.(38p7)\u003c/p\u003e\n\u003cp\u003ePersonal Advisors\u003c/p\u003e\n\u003cp\u003eLocal Authorities (LAs) are mandated to provide a Personal Advisor (PA) to support care leavers up to the age of 25. PAs are expected to ensure that care leavers have the support they need, and to coordinate and review the services needed to implement the young person\u0026rsquo;s \u0026lsquo;Pathway Plan\u0026rsquo;. The Pathway Plan is required for all care leavers; it is designed to facilitate successful transition(\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e) and covers 8 eight areas of their lives, including their \u0026lsquo;health and development\u0026rsquo; and \u0026lsquo;emotional and behavioural development\u0026rsquo;. The Pathway Plan should include details of a young person\u0026rsquo;s health needs and how these should be met, and the development of this plan should be supported by annual Health Assessments undertaken while in care. Care Leavers should be provided with a Health Passport when they leave care, summarizing their health history and needs for their own future reference. PAs are expected to take reasonable steps to ensure that the young person makes use of the services identified in the Pathway Plan and to remain informed about their progress and wellbeing. (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eThe expectations of the PA are set out in the Children and Social Work Act 2017 and in the description of the \u0026lsquo;named worker\u0026rsquo; in NICE guideline NG43.(\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e) Statutory guidance (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e) makes clear that PAs \u0026lsquo;should have access to information and training about how to promote physical and mental health\u0026rsquo; (p.26), to work in partnership with CLs and those health professionals involved in their health assessments, and to ensure that CLs have all the information they need to manage their own health. For those with complex needs, including disabilities, who do not meet the criteria for support by adult services, the PA should ensure that all possible forms of support are identified and made available.\u003c/p\u003e\n\u003cp\u003eDespite the statutory force of the guidance, health is rarely a major focus for PAs, who are primarily concerned with basic provision of housing and money. (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e) Whilst appropriate accommodation is essential for mental and physical health and wellbeing, many care leavers report that insufficient attention is given to their health needs, particularly their mental health needs and as the Care Quality Commission noted, most lack adequate health support.(44 p.36)\u003c/p\u003e\n\u003cp\u003eAs adults with whom CLs have (ideally) already formed a supportive relationship, the PA is well placed to promote their health and wellbeing, and their use of health services. However, PA provision varies considerably across LAs, (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) and there is currently no prescribed professional qualification for PAs, other than to have a working knowledge of the issues a care leaver might face as they make their transition into adulthood, and the legal framework in relation to this. Little is known about in-service training provided by LAs, or the supervisory arrangements in place to support them in executing their role.\u003c/p\u003e\n\u003cp\u003eWithout an explicit curriculum to equip PAs to address issues of health and wellbeing, it is unsurprising that these issues are seldom addressed. In preparing their transition Guideline in 2016, (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e) NICE was unable to identify any studies on the effectiveness of \u0026lsquo;transition training\u0026rsquo; for practitioners responsible for supporting young people using children\u0026rsquo;s health or social care services \u0026lsquo;before, during and after transition\u0026rsquo; (2.9) The Care Leavers Association has recommended better training for PAs, particularly in relation to mental health.\u003c/p\u003e\n\u003cp\u003eAims\u003c/p\u003e\n\u003cp\u003eThe aim of the \u003cem\u003eImproving Health Outcomes for Care Leavers: the Life in Transition\u003c/em\u003e (LIFT) study was to establish the feasibility and acceptability of a future, definitive trial of the effectiveness and cost-effectiveness of a brief training programme designed to better equip Personal Advisors (PAs) to support care leavers (CLs) with a wide range of health issues. Conducting randomised trials in local authority children\u0026rsquo;s services departments can be challenging (\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e) and the study was designed to address two key aims: (i) to explore the views of personal advisors on the relevance and acceptability of the training and (ii) to ascertain whether a pragmatic trial was feasible.\u003c/p\u003e\n\u003cp\u003eOur primary objective was to ascertain the feasibility of key procedural elements that would need to form part of an experimental evaluation of the effectiveness of the training intervention, including: whether it is possible to train and retain all PAs in each participating authority; whether it is possible to recruit and retain a sample of CLs in each arm of the study to a 12 months follow-up, and whether it is possible to secure blinding of outcome assessors.\u003c/p\u003e\n\u003cp\u003eOur secondary objectives were to\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eEstablish the acceptability and feasibility (data burden and cost), and the factors influencing the completion of measures at baseline (PAs and CLs), post training (PAs) and follow up (PAs and CLs).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eCollect outcome measures and assess their performance and quality with this population (acceptability, completeness, means, variability and distribution of scores).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eUse the data collected to estimate the Intra-cluster Correlation Coefficient (ICC) to inform the sample size requirements for a main trial.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eDetermine the feasibility and cost of accessing and using administrative data, if available\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAscertain the acceptability of randomisation to LAs and PAs\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eConsider the implications of any contamination between the two arms of the trial e.g. PAs moving between teams in different trial groups.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIdentify barriers and facilitators to implementation of, and fidelity to, the intervention.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eTo use the information gathered to inform the design of a pragmatic trial, if this seems feasible, including establishing appropriate progression criteria for an internal pilot to the main trial.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Methods","content":"\u003cp\u003eTrial design and random allocation\u003c/p\u003e\n\u003cp\u003eThis was a multi-centre, cluster-randomised feasibility trial. We randomised at the level of PA teams within each of three local authorities, using a 2:1 allocation ratio (two teams to the intervention, one to the control group). We adopted a 2:1 ratio for a number of reasons, First, each of the three participating local authorities had three PA teams and exposing larger numbers of PAs to the training provided a stronger basis on which to assess the perceived relevance and acceptability of the training and the acceptability of the data collection demands on PAs. It also increased the feedback to the research team as to how the training might be amended or further developed. A secondary consideration was the likely acceptability of this approach to randomisation within the local authorities. Whilst every care was taken to emphasise that the study was designed to test the feasibility of the study design, and not to evaluate the training \u0026ndash; which might or might not be effective - managers were keen to offer training to this staff group, for whom little training specifically targeted their role.\u003c/p\u003e\n\u003cp\u003eThe random allocation sequence was generated by CM, whilst masked to the identity of the nine participating teams, and with no involvement in recruiting LAs to the study.\u003c/p\u003e\n\u003cp\u003eHypothesised mechanism of effect\u003c/p\u003e\n\u003cp\u003eOn the basis of consultations with PAs and CLs, and relevant literature, we hypothesised that by improving their knowledge of a range of health issues relevant to young people transitioning from care, and developing certain skills, PAs would be more likely to \u003cem\u003erecognise\u003c/em\u003e the health needs of care leavers, to \u003cem\u003ebe able to raise health matters\u003c/em\u003e and \u003cem\u003eto talk to care leavers\u003c/em\u003e about health, including what they might regard as challenging topics, such as sexual health, self-harm or substance misuse. We also expected PAs to be more likely to \u003cem\u003efacilitate access to health resources\u003c/em\u003e and to support young people to \u003cem\u003etake steps to protect or improve their own heath\u003c/em\u003e. The logic model and theory of change developed for the intervention can be found in Supplementary File 1.\u003c/p\u003e\n\u003cp\u003eOutcomes and outcome measures\u003c/p\u003e\n\u003cp\u003ePossible measures were identified from a review of the literature, searches of PubMed and Web of Science, with input from the study\u0026rsquo;s Programme Management Group. Possible tools were compared, taking into account their previous use in similar populations, validation studies, language used and length. The final selection was made in consultation with experienced young people, and comprised the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003ePersonal wellbeing, using four questions from the ONS survey (\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e);\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePhysical health status, using three questions from the ONS survey (\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e);\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eSelf-efficacy / confidence in securing health information and support from professionals (Health Literacy), using the 10-item Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI-10) (\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e);\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003ePsychological coping (Mastery), using the 7-item Pearlin Mastery Scale (\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e);\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eQuality of life. We used three measures of quality of life, one in each of the three sites, to explore their relative acceptability and sensitivity to quality of life amongst this group of young people: the EuroQoL Health-related Quality of Life Measure (EQ5-5D-5L) (\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e), the 20-item Recovering Quality of Life (ReQoL20) (\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e) and the 10-item Recovering Quality of Life (ReQoLl0) (\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e);\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eHealth service usage, using the Client Service Receipt Inventory as the basis, which is a reliable and valid resource use measurement tool. The tool was modified to collect data on health service use only to estimate cost consequences of support from a trained PA;\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIn addition, we asked each care leaver five questions designed to assess their perceptions of PA empathy.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWith the exception of health service use, the time points for data collection were baseline, 24 and 48 weeks after each baseline interview was completed. Health service use data were collected at baseline and bi-monthly telephone calls.\u003c/p\u003e\n\u003cp\u003ePersonal Advisors who agreed to participate in the study were asked to complete a questionnaire at baseline. This asked questions about how often health, and other topics, were covered in their contacts with care leavers, their knowledge and use of health passports, their confidence in their knowledge of key aspects of health and in raising these with care leavers, and what they saw as the barriers to supporting care leavers with health issues.\u003c/p\u003e\n\u003cp\u003eThose who completed the training were asked to complete a post-training questionnaire. This covered their perceptions of the relevance of the modules to the CLs with whom they work and whether they provided sufficient knowledge to identify, raise and address the health issues covered (i.e. \u0026lsquo;content, \u0026lsquo;dose\u0026rsquo; and \u0026lsquo;level\u0026rsquo;); the extent to which they think organizational factors are likely to support or impede changes to their practice, including, for example, internal factors such as caseloads; administrative systems, line management support, and external factors such as the availability, capacity and responsiveness of other services; what impact they think it might have on their practice, and how it might benefit the young people with whom they work.\u003c/p\u003e\n\u003cp\u003eQualitative data\u003c/p\u003e\n\u003cp\u003eIn addition to the data collected via online surveys, we interviewed a sample of personal advisors and all participating care leavers at baseline. Care leavers were also asked to be available for two further interviews at 24 and 48 weeks post-baseline data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal advisors\u003c/strong\u003e Once training was complete, we interviewed a sample of personal advisors in both arms of the trial. For PAs in the control group the interview explored their experiences of participating in the trial, specifically their thoughts and feelings about being in the control group, including their willingness to comply with the data requests that formed part of the study; to understand the local context during the period of the study, the health issues they encounter in their work and how they respond to these, the training they have received on various health issues, and what training they needed. Those in the intervention group were also asked how helpful the training had been and in what ways, and what the barriers and facilitators were to using what they had learned.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare leavers\u003c/strong\u003e The baseline interview with CLs explored their relationship with their PA, an overview of how they viewed their physical and mental health and wellbeing, their use of health services, the extent to which health issues are discussed with their PA and how raises them, and the use made of health passports and pathway planning.\u003c/p\u003e\n\u003cp\u003eSubsequent interviews comprised the candidate outcome measures for a full trial, together with questions on the extent to which they felt their health needs (including emotional health and wellbeing) had been recognized and addressed by their PAs in the previous six months. The interviews explored how often they had seen their PA; whether PAs have brought up topics covered in training modules (including help seeking, smoking, alcohol and substance use, sexual health, nutrition and exercise); what their own health and wellbeing concerns were and whether or not they had felt able to bring these to the attention of their PA; what the response was, and how helpful their PA had been more generally in helping them to address their health issues. We also enquired how the CL felt about health issues being raised by the PA, and whether or not they subsequently took any steps to address them. At the final interview we also asked about their experiences of participating in the trial, and what their advice would be to a research team wanting to conduct a larger study.\u003c/p\u003e\n\u003ch3\u003ePersonal Advisors\u003c/h3\u003e\n\u003cp\u003eThe interviews with intervention PAs asked them for their views on the training (helpfulness of the component parts, coverage, \u0026lsquo;pitch\u0026rsquo;), other training they had received on health-related matters, or would like to receive, and questions about their use of health passports and pathway plans in their work with care leavers. Interviews with control PAs asked about caseloads, the allocation of work, the sorts of health issues they encounter and how they dealt with them, training received and training they would like, plus experience of being in the research study (their views on being in the control group, of being asked to complete surveys and be interviewed) and expectations for the future (expecting to receive the training, their views on the topic). We also asked control group PAs whether any of the young people they worked with had spoken to them about being in the study, or whether they had spoken to any intervention PAs or learned about the content of the training.\u003c/p\u003e\n\u003cp\u003eBuilding on previous experience in using peer researchers as a means of securing high quality information from care experienced young people, we collaborated with CORAM Voice to help recruit, train and support a group of peer researchers to collect data (by telephone) from care leavers. The protocol stipulated that the peer researchers would conduct the interviews with care leavers, and in the final interview, a particular focus of the conversation was to elicit their views on the use of peer researchers, as well as the incentives offered; what information they would want to know about the findings of the trial, and in what format.\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eThe intervention is directed at PAs, but the intended beneficiaries are young people leaving care. The legal definition of a care leaver is someone who has been in the care of the Local Authority for a period of 13 weeks or more spanning their 16th birthday [The Children (Leaving Care) Act 2000.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCLs in the three participating local authorities (Bristol City Council, Gloucestershire County Council, and Nottinghamshire County Council) who were over the age of 16 years at baseline and allocated to a Leaving Care Team for the first time in a four month period which began 2 months prior to baseline data collection.\u003c/p\u003e\n\u003cp\u003eWe excluded the following groups of care leavers: care leavers who were living in foster care (other than \u0026lsquo;Staying Put\u0026rsquo; foster care), who were in a residential or secure setting of any kind, or themselves had an allocated social worker for reasons other than being a care leaver (for example, as a result of being a parent themselves) and those deemed by the local authority to present a risk to themselves or to research staff.\u003c/p\u003e\n\u003cp\u003eRecruitment and consent\u003c/p\u003e\n\u003ch2\u003eCare Leavers\u003c/h2\u003e\n\u003cp\u003eEach LA distributed study participant information leaflets to eligible CLS along with letters of invitation to participate in the study. In addition, a member of the research team attended drop-in sessions (or similar) organised by the LA to talk about the study in person. Care was taken to make clear that young people were not obliged to take part in the study.\u003c/p\u003e\n\u003cp\u003eFollowing an expression of interest from a CL, a member of the research team arranged to meet with them to ascertain eligibility, ensure that they fully understood what the study entailed, and that \u0026ndash; should they agree to participate \u0026ndash; that they could withdraw at any time without giving any reason, and without prejudice to the services they receive. Most meetings were online or by telephone, but some were in person, depending on circumstances and the young person\u0026rsquo;s preference.\u003c/p\u003e\n\u003ch3\u003ePersonal advisors (PAs)\u003c/h3\u003e\n\u003cp\u003ePAs were notified of the study by their employing authority who distributed a Participant Information Leaflet designed for local authority staff. Whilst PAs were expected by their employer to participate in the training, they were asked to consent to participate in the study. Staff were asked by senior managers to attend an online briefing session to introduce them to the study and to invite them to participate. All information provided, both written and verbal, emphasised that the study was designed to explore the impact of a training intervention rather than the practice of individual PAs or teams. Some LAs had staff who focused solely on housing support for care leavers. The training programme was available to these staff, but they were not eligible for the study.\u003c/p\u003e\n\u003cp\u003eAll recruitment was undertaken by the research team, supported by colleagues from the Clinical Research Network serving the area.\u003c/p\u003e\n\u003cp\u003eIntervention\u003c/p\u003e\n\u003ch3\u003eOverview\u003c/h3\u003e\n\u003cp\u003eThe training programme was developed by a multidisciplinary team comprising health specialists, social workers, PAs, LA managers and care experienced young people. The programme was informed by an international review of what we know about the health of care experienced young people, a national survey of PAs and their managers about what training is needed, and consultations with care experienced young people, PAs, and other stakeholders from health and other sectors.\u003c/p\u003e\n\u003cp\u003eThe training comprised a blend of webinars, six online modules (hosted on NIHR Learn), and a skills workshop facilitated by two health professionals, at least one of whom was familiar with children in care or care leavers. The PI met twice with intervention PAs; first to take feedback on the modules, and later to collect information on the progress they made towards achieving their personal goals, and what \u0026ndash; if anything \u0026ndash; the barriers and facilitators were to this (see Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eOverview of Training for Personal Advisors\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDelivery\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTime required of participants\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFacilitated by\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntroduction to the training (and study)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWebinar 1/Briefing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 hour maximum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResearch PI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSix Online Modules\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNIHR LEARN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3-hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLA Managers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIdentifying key issues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWebinar 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5 hours.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResearch PI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWorkshop\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOne day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAction Plan Implementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDay to day practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThree weeks, part of routine practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParticipants/ Skills leaders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal Group Session\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIn person\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHealth professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch3\u003eThe modules\u003c/h3\u003e\n\u003cp\u003eModules combined written information with short videos, and tasks (Supplementary File 2). Line managers agreed to allow dedicated time for PAs to complete these over the course of a couple of weeks.\u003c/p\u003e\n\u003ch3\u003eThe skills workshop\u003c/h3\u003e\n\u003cp\u003eEach skills workshop was facilitated by a Named Doctor for Children in Care within each of the local authorities and another health colleague. In one site this was a GP trainee, in another an Adoption Medical Advisor, and in the third a Named Nurse. The workshop manual provided facilitators with information on the background to the study, the content of the online modules, and detailed guidance on how to deliver the workshop. The workshop aimed to help participants apply the learning from the online modules and focused specifically on the development of the skills required to raise health issues in ways that are acceptable to young people, to help young people to appreciate the importance of health, and what they can do to stay healthy and well. It began with introductions, housekeeping, the aims of the workshop and ground rules. The facilitator then presented an overview of what distinguishes effective helpers and the skills associated with effective communication e.g. conveying accurate empathy, warmth and genuineness, asking open ended questions, using affirmation, reflective listening and summarizing, asking difficult questions or raising sensitive issues, such as substance misuse, sexual health etc. This was followed by a session in which participants considered a series of vignettes and practiced key skills such as identifying open ended questions or considering ways in which they might start a conversation around a sensitive topic. The remainder of the workshop comprised a series of \u0026lsquo;real world\u0026rsquo; scenarios role plays i.e. role plans based on situations faced by Personal Advisors, appropriately anonymised. Participants were divided into two or three groups (depending on the scenario) and given partial information, relevant only to the \u0026lsquo;character\u0026rsquo; they were role-playing. One member of each group then played a young person and a Personal Advisor, and \u0026ndash; where relevant \u0026ndash; a third party, such as a health visitor. There was some flexibility afforded facilitators into how best to approach the role plays, and participants could select which scenarios they want to focus on. As well as affording participants with opportunities to practice communication skills, and to use their knowledge of health issues from the modules and elsewhere, the workshops enabled participants to improve their knowledge of the organisation of health services (via discussion with the facilitators) and to see each other \u0026lsquo;in practice\u0026rsquo;, something PAs are rarely able to do.\u003c/p\u003e\n\u003cp\u003eHandouts were provided that summarised the evidence on what makes for effective helpers, effective change talk, effective interviewing skills, plus a handout on adverse childhood experiences and trauma-informed practice.\u003c/p\u003e\n\u003cp\u003eAt the end of each workshop PAs were asked to complete a self-assessment of their perceived abilities in respect of ten communication skills covered in the workshop using a 10-point Likert scale. Examples of the items include:\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I am able to use limited self-disclosure and humour where appropriate\u0026rsquo;.\u003c/p\u003e\n\u003cp\u003eI can ask questions in the context of uncertainty, where my knowledge is limited.\u003c/p\u003e\n\u003cp\u003eThey were also asked to set themselves at least one SMART goal, and to consider what evidence of success would look like. They were asked to provide their line manager with a copy of their goals so that these could be discussed in supervision and expected to report on these at the follow-up group session. Copies of the Manual are available from the contact author.\u003c/p\u003e\n\u003cp\u003eChanges in design\u003c/p\u003e\n\u003cp\u003eFollowing a pause in the study due to the COVID-19 pandemic, the feasibility study was scheduled to commence in September 2022 and the three participating local authorities were expecting their staff to be trained in October 2022. Prior to pausing the study, all planned data collection had been agreed and, in February 2022, submitted to the CTU responsible for organising the online REDCap surveys and databases. The Bristol Trials Centre was unable to develop the REDCap surveys and database in time for this schedule, due to competing demands from other paused studies restarting during 2022, and increased demands from studies that had to move some of their activities to the online format. This meant that we were unable to start recruitment until December 2022, which was problematic as the local authorities advised us that December and early January were not optimal times to train PAs. In order to mitigate the delays, we agreed the following changes with the funder, with the support of the Trial Steering Committee (TSC):\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eDeferring the recruitment of care leavers, to enable the REDCap data base for PAs to be prepared in a shorter time. We anticipated that we could still recruit Care leavers prior to the PAs finishing their training.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eWe amended the eligibility criteria for recruiting care leavers, to open recruitment out to any care leaver. The original restrictions on eligibility criteria were designed primarily to manage expectations, and also because we thought it might be easier to detect any impact of the training. However, although local authorities had informed us otherwise, we initially struggled to recruit care leavers, particularly in one local authority. Broadening our recruitment strategy to include social media helped to address this.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eShortening the planned follow-up periods by two weeks, so collecting data at baseline, 24 and 48 weeks post-randomisation, rather than 26 and 52 weeks. This was because, despite staggering the recruitment of personal advisors and care leavers, it took longer than anticipated to complete the training and, in particular, to schedule the Skills Workshops and final group meetings with the PI.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn addition, we made the following changes:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eWe dropped the PEPPI-10 (\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e) at the final follow up with care leavers, because they reported frustration at being asked what seemed to them to be \u0026lsquo;the same questions\u0026rsquo; in the interviews, and in light of what interviewers perceived to be an evident ceiling effect.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eAfter several attempts, we abandoned the use of peer researchers to conduct the interviews with care leavers and took these \u0026lsquo;in house\u0026rsquo;. Essentially, it proved too difficult to arrange for those recruited as peer researchers to conduct interviews due to other commitments.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eIn our proposal we had proposed some provisional progression criteria, but following discussion with the TSC it was agreed that these were inappropriate for this feasibility trial, which was neither part of a programme grant, nor the pilot for a pragmatic trial where such criteria would inform the \u003cem\u003einternal\u003c/em\u003e stop/go decision. It was also recognised that it was likely that a great deal might change between the completion of this trial and any proposal to seek funding for a pragmatic trial. With the funder\u0026rsquo;s agreement, we therefore amended our focus to using the information gained in this trial to:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eHelp clarify which aspects of the training are \u0026lsquo;essential\u0026rsquo; and which are \u0026lsquo;useful\u0026rsquo; (and whether this categorisation differs according to the pre-existing knowledge and experience of personal advisors),\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eDetermine how best to further develop the training so that it could, in principle, be \u0026lsquo;rolled out\u0026rsquo; into practice, if a future trial suggested it was helpful to PAs in supporting care leavers with health issues, and\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eGather information on the methodological issues, such as our ability to recruit and retain care leavers, and the appropriateness of the measures we are using (e.g. acceptability and any ceiling effects) that might inform the number of sites and number of potential participants for a pragmatic trial.\u003c/p\u003e\n \u003c/li\u003e\u003cbr\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eWe learned early on that it would not be possible to access useful administrative data e.g. to identify eligible care leavers or use records in health passports or pathway plans. Despite budgeting for administrative support within the local authorities, we were told this would not be possible given the organisation of records.\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMeasures used to assess the feasibility outcomes\u003c/p\u003e\n\u003cp\u003eThe approach adopted to establishing feasibility in respect of the primary and secondary objectives is set out in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e: Feasibility outcomes and means of assessment2.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eFeasibility outcomes and means of assessment.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eObjective\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOUTCOME\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHow assessed\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003ePRIMARY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePA recruitment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% per LA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePA retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% of those recruited per LA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCL recruitment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCount of CLs randomised\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTarget sample size reached\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCL retention to 12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% of those recruited\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMasking of outcome assessors (interviews)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsking interviewers to record whether interviewee has an intervention or control PA \u0026ndash; best guess if they don\u0026rsquo;t know (two-alternative forced choice)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eSECONDARY\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcceptability of data collection (burden and cost)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% CLs completing surveys and interviews at each time point\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e% of PAs completing surveys and interviews at each time point\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors influencing training completion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterviews with PAs and CLs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerformance of outcome measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcceptability \u0026ndash; interviews with CLs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompleteness, means, variability and distribution of scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcceptability of randomisation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInterviews with PAs and CLs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEvidence of contamination across intervention and control arms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInformation from LAs regards staff movements\u0026thinsp;+\u0026thinsp;Interviews with PAs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eImplementation fidelity and cost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMonitoring of module completion by PAs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePA Attendance at Skills Workshop\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObservation of Skills Workshops\u003c/p\u003e\n \u003cp\u003eCost of the time and resources required to set up and deliver the intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEstimate of the Intra-cluster Correlation Coefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFor the likely primary outcome measure, the ICC will be estimated with 95% confidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAdverse events and Harms\u003c/p\u003e\n\u003cp\u003eThese were defined as any unexpected or adverse event occurring in the conduct of interviews with care leavers i.e. as a direct result of the interview or concerns about the safety and wellbeing of care leavers that emerged within the interview. In accordance with an agreed protocol for dealing with harms or adverse events, with the care leaver\u0026rsquo;s knowledge, these were reported to the PI and to the relevant local authority and followed up until resolved.\u003c/p\u003e\n\u003cp\u003eFeasibility study sample size\u003c/p\u003e\n\u003cp\u003eGiven the primary aims of this study were to ascertain the feasibility of those key procedural elements that would need to form part of a definitive cluster-randomised trial of the effectiveness of the training intervention, we judged that recruiting nine PA teams from three local authorities would be sufficient. We also judged that recruiting 20 CLs from each LA would provide the information required to judge the feasibility of a definitive trial.\u003c/p\u003e\n\u003cp\u003eMasking\u003c/p\u003e\n\u003cp\u003eIt was not possible to mask participating PAs because of the nature of the intervention. CLs were not aware of the study status of their PA. Because the research team was responsible for organising and providing the training, it was not possible to mask the research team to the allocation status of PA teams. It was hoped that we could mask the peer researchers to the trial arms to which care leavers belonged but a consequence of taking the CL interviews \u0026lsquo;in house\u0026rsquo; it was difficult to achieve 100% masking in relation to CL interviews.\u003c/p\u003e\n\u003cp\u003eAnalyses\u003c/p\u003e\n\u003cp\u003eData relevant to the feasibility of recruitment, treatment delivery, and participant retention will be presented in the CONSORT flowchart. Appropriate summary statistics will be presented by allocated group for each questionnaire measure completed by participants, to demonstrate the completion rate and sensitivity to effects of the intervention. For costing resource use, nationally applicable unit costs were sourced and are presented in Supplementary File 3 (Tables S1 and S2). All activities were costed at 2023/24 UK prices. For costing the health services resource use, subtotals for each of the cost categories were calculated and a total mean cost per care leaver presented by allocated group, along with the mean cost difference and bootstrapped 95% confidence intervals to understand the distribution of costs.\u003c/p\u003e\n\u003cp\u003eThe intra-cluster correlation coefficient will be estimated for the potential primary outcome(s) of the definitive trial using a variance components model and presented with its 95% confidence interval. Qualitative data were analysed using Framework Analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant flow\u003c/p\u003e\n\u003cp\u003eFigure 1 summarises the numbers of both PAs and CLs at each stage of the trial. The dip in data collection from care leavers coincides with the difficulties encountered in organising peer researchers to conduct the follow-up interviews at this time. We recruited 63 of the 76 eligible PAs working in the three local authorities. Of those who consented, one later withdrew from the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFigure 1: CONSORT flowchart\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003ePLACE FIGURE 1 HERE\u003c/h3\u003e\n\u003cp\u003eCharacteristics of participants\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e provides an overview of the characteristics of participating personal advisors. Participating PAs were typically female, full-time, and had been in the job for about two years. PAs in each arm were broadly comparable in terms of gender and caseloads, with no obvious imbalance in terms of years of experience: compared with those in the control group, rather more PAs in the experimental arm had only two years or less experience (67% v 58%) and fewer PAs with three years or more (33% v 53%) but numbers are small.\u003c/p\u003e\n\u003cp\u003eNot evident from Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e is the heterogeneity of career backgrounds of the sample as a whole, which ranged from someone with years of experience as a head teacher to PAs with very limited prior experience in working with young people.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of personal advisors and caseloads by allocated groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup allocation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComparison (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompleted baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber female (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime as a personal advisor:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber\u0026thinsp;\u0026lt;\u0026thinsp;1 year (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber 1\u0026ndash;2 years (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber 3\u0026ndash;5 years (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber\u0026thinsp;\u0026gt;\u0026thinsp;5 years (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber full-time (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean caseload (SD*)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (3.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean new cases in past year (SD*)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCases met before they left care\u003cstrong\u003e^\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMost\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e*SD\u0026thinsp;=\u0026thinsp;Standard Deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e^\u003c/strong\u003e Refers to the number of care leavers with whom PAs started work before the former left care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare leavers\u003c/strong\u003e Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e summarises the characteristics of the CLs who took part in the study. Again, these were typically female, white and with a mean age of 19 years. Just over half were not in education, employment, or training. At follow-up, 20% of the CLs in the intervention group (9/46) saw a change in household composition and 26% (12/46) saw a change in accommodation type. Figures for those in the comparison group were 38% (9/24) and 25% (6/24) respectively.\u003c/p\u003e\n\u003cp\u003eFurther details on recruitment and participation can be found in Supplementary File 4 (Tables S1 and S2).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCare leaver characteristics by allocated group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComparison (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMean age in years (SD), N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (1.3), 46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (1.6), 24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of females / N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 / 44 (68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 / 24 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber with gender identity same as birth sex / N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 / 43 (88%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 / 23 (96%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnic group\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eNumber White (%)\u003c/p\u003e\n \u003cp\u003eNumber Mixed or multiple (%)\u003c/p\u003e\n \u003cp\u003eNumber Asian or Asian British (%)\u003c/p\u003e\n \u003cp\u003eNumber Black or Black British (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 responding\u003c/p\u003e\n \u003cp\u003e33 (72%)\u003c/p\u003e\n \u003cp\u003e5 (11%)\u003c/p\u003e\n \u003cp\u003e5 (11%)\u003c/p\u003e\n \u003cp\u003e3 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 responding\u003c/p\u003e\n \u003cp\u003e21 (88%)\u003c/p\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent occupation\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eNumber in education (%)\u003c/p\u003e\n \u003cp\u003eNumber in training / employment (%)\u003c/p\u003e\n \u003cp\u003eNumber not in education, training or employment (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 responding\u003c/p\u003e\n \u003cp\u003e5 (11%)\u003c/p\u003e\n \u003cp\u003e14 (30%)\u003c/p\u003e\n \u003cp\u003e27 (59%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 responding\u003c/p\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003cp\u003e8 (33%)\u003c/p\u003e\n \u003cp\u003e14 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber reporting no qualifications / N (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 / 46 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 / 25 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eNumber living with non-family adults in house-share (%)\u003c/p\u003e\n \u003cp\u003eNumber living with partner or family (%)\u003c/p\u003e\n \u003cp\u003eNumber living alone (%)\u003c/p\u003e\n \u003cp\u003eNumber living with partner \u0026amp; children (%)\u003c/p\u003e\n \u003cp\u003eNumber living with children only (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 responding\u003c/p\u003e\n \u003cp\u003e11 (26%)\u003c/p\u003e\n \u003cp\u003e6 (14%)\u003c/p\u003e\n \u003cp\u003e21 (49%)\u003c/p\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003cp\u003e4 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 responding\u003c/p\u003e\n \u003cp\u003e7 (29%)\u003c/p\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003cp\u003e8 (33%)\u003c/p\u003e\n \u003cp\u003e3 (13%)\u003c/p\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of accommodation\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eNumber in family home (%)\u003c/p\u003e\n \u003cp\u003eNumber In supported lodgings (%)\u003c/p\u003e\n \u003cp\u003eNumber in ordinary lodgings (%)\u003c/p\u003e\n \u003cp\u003eNumber with no fixed abode (%)\u003c/p\u003e\n \u003cp\u003eNumber living with former foster carers (%)\u003c/p\u003e\n \u003cp\u003eNumber living in other accommodation (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 responding\u003c/p\u003e\n \u003cp\u003e4 (9%)\u003c/p\u003e\n \u003cp\u003e9 (20%)\u003c/p\u003e\n \u003cp\u003e22 (49%)\u003c/p\u003e\n \u003cp\u003e5 (11%)\u003c/p\u003e\n \u003cp\u003e2 (4%)\u003c/p\u003e\n \u003cp\u003e3 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24 responding\u003c/p\u003e\n \u003cp\u003e2 (8%)\u003c/p\u003e\n \u003cp\u003e7 (29%)\u003c/p\u003e\n \u003cp\u003e13 (54%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eResults for the feasibility outcomes\u003c/p\u003e\n\u003cp\u003eDetails of the data collected from PAs and CLs at baseline and follow up are presented in Supplementary File 4. No unintended effects or significant harms were reported or identified.\u003c/p\u003e\n\u003cp\u003ePrimary Outcomes\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e1. Recruitment\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal advisors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhilst PAs were invited to participate in the study (i.e. providing data) their employers expected them to complete the training irrespective of their participation in the study. Of the 76 eligible PAs, 63 were recruited to the study (83%). Four members of the participating teams had specialist support roles e.g. housing support and were not eligible to participate in the study. They were not excluded from the training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare leavers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCLs were recruited by the study team from both PA who participated in the study (n\u0026thinsp;=\u0026thinsp;35) and those who did not (n\u0026thinsp;=\u0026thinsp;5). Recruitment of care leavers improved with a broadening of recruitment avenues, including research staff attending drop-ins and use of social media.\u003c/p\u003e\n\u003cp\u003eNo CLs were recruited from the caseloads of the remaining 28 PAs who took part in the study (Table \u003cspan class=\"InternalRef\"\u003eS1\u003c/span\u003e, Supplementary Materials).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e2. Retention and completion of measures under consideration for a future trial\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eOne PA withdrew from the study at module completion stage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal advisors\u003c/strong\u003e. Of the 63 PAs who consented to participate in the study, 58 completed the baseline pre-training survey (92%), 32 completed the first follow-up interview and 35 (56%) the final follow-up interview.\u003c/p\u003e\n\u003cp\u003eTwenty-eight of the 39 PAs in the intervention arm completed the post-training survey (72%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare leavers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 71 CLs who consented to participate in the study, three withdrew in the course of the study, for personal reasons (two from the intervention arm and one from the control arm).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eMasking of outcome assessors (interviews)\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal Advisors\u003c/strong\u003e In the event, interviewers were not masked to the allocation status of PAs because follow-up interview schedules for intervention PAs included questions about the impact of the training on their practice, and \u0026ndash; at baseline - interviews with those in the control group included questions about their views on their allocation to that arm of the trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare leavers\u003c/strong\u003e With the exception of the senior researcher employed on the study, it was clear that masking interviewers to the allocation status of CLs was feasible. De facto, masking was not 100% in this study because it did not prove possible to use peer researchers. Instead, we recruited two post-doctoral fieldworkers to conduct around one half of the interviews. The senior researcher was not masked to status because she was responsible for allocating interviews. The other researchers were unaware of the status of those they interviewed.\u003c/p\u003e\n\u003cp\u003eSecondary Outcomes\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e4. Acceptability of data collection (burden and cost)\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal Advisors\u003c/strong\u003e All but 5 of the 63 PAs recruited completed the baseline questionnaire (92%), but this dropped to 32 (51%) and 35 (56%) at first and second follow-up survey respectively. Of the 39 PAs in the intervention group, 28 (72%) also completed the post-training survey.\u003c/p\u003e\n\u003cp\u003eAt baseline, the majority of PAs said they were either \u0026lsquo;very pleased\u0026rsquo; or had \u0026lsquo;no particular feelings\u0026rsquo; about taking part in the study, and all but 11 said they were happy with the proposed data collections planned in the following 12 months. The remaining PAs said they would rather not have to speak to a researcher on two occasions in the next 12 months but didn\u0026rsquo;t mind doing so.\u003c/p\u003e\n\u003cp\u003eAt the end of the study, those intervention PAs who gave general comments about trial participation reported no concerns about the data collection tools or number of contacts, other than about the timing and communication regarding some of the study events (two PAs in LA 2). Three intervention PAs mentioned finding participation in the study worthwhile, one who hadn\u0026rsquo;t completed the training due to absence welcomed the opportunity to feedback on health issues for CLs in the interview.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I think I was just glad of the experience and I\u0026apos;ve taken a lot from it and I am very thankful to have been a part of it.\u0026quot;\u003c/em\u003e\u003cstrong\u003e(LA 3 Participant 5 - intervention)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eOf the six PAs in the control group, all found the study requests and contacts from the study team to be reasonable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCare leavers\u003c/strong\u003e At the first follow-up 37 CLs were interviewed (52%) and at the second follow-up 49 were interviewed (69%). Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e summarises the completion of the bi-monthly Health Service Use questions and interviews conducted at the two follow-ups. The 6- and 12-months collection of Health Service Use data was included in the interviews (mostly conducted by telephone); those at 2, 4, 8, and 10 were collected by telephone. In respect of the collection of health service use data, we received information from 41 at 2 months follow-up (69%) 33 at four months, 24 at 8 months and 39 at 10 months (55%). Given this population is generally considered \u0026lsquo;hard to reach\u0026rsquo; the completion rates suggest that the data burden was acceptable. The outcome measures used were administered by research staff.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCompletion rates of data collection from Care Leavers\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHSU\u003c/p\u003e\n \u003cp\u003e2 months\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHSU\u003c/p\u003e\n \u003cp\u003e4 months\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up 24 weeks\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHSU 8 months\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHSU\u003c/p\u003e\n \u003cp\u003e10-months\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003cp\u003e48 weeks\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e47 (66%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e33 (47%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e42 (59%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e34 (48%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e39 (55%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e52 (73%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e\u003csup\u003e1\u003c/sup\u003e Includes HSU questions\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eCompleteness of the health service use questionnaire suggested that it was acceptable to care leavers (Supplementary File 3, Table \u003cspan class=\"InternalRef\"\u003eS3\u003c/span\u003e). Use of primary care services and community care services were well reported in that service use could be costed appropriately. The categories of secondary care services and medication use had the highest proportion of incomplete data (16.9% and 13.4%, respectively), indicating that greater care may be needed in collecting data for these items, or alternative sources identified such as electronic healthcare records.\u003c/p\u003e\n\u003cp\u003eThe mean costs per CL by category of health service use are presented in the tables in Supplementary File 3, along with the mean cost difference and bootstrapped 95% confidence intervals. There were no differences observed between the two groups on total mean cost per CL (mean cost difference: -\u0026pound;211.00; bootstrapped 95% CI: -\u0026pound;1111.99 to \u0026pound;617.99), nor by cost category. Cost drivers were the secondary care service use, which included out of hours services, 999/111 calls, ambulance services, emergency department attendances, hospital admissions, and hospital outpatient services. Thus, reiterating the need for greater care to be taken during data collection to elicit valid responses in a full trial. Community care service use was also a cost driver for both groups, which was indicative of the inclusion of costs associated with the personal advisor, as well as community mental health services.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e5. Completion of training\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of PAs appear to have engaged with between 5 and 6 modules, but information on the \u003cem\u003eextent\u003c/em\u003e to which PAs fully engaged with the six modules is limited for two reasons. First, the platform used to host the modules only allowed us to identify which modules individual PAs had opened. Second, we know that in the LA that set aside one day for the two intervention teams to complete the modules together, the arrangement did not work well (see below).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e6. Factors influence completion of training\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eViews on the training were gathered at the second webinar and in interviews with a subsample of seventeen PAs. They also emerged at the Skills workshops.\u003c/p\u003e\n\u003ch3\u003eMode of delivery and time required\u003c/h3\u003e\n\u003cp\u003eManagers in two LAs agreed to make time available within the working week for PAs to complete the training over a period of 2\u0026ndash;3 weeks. This was what was intended, but the third LA the Service Manager made the decision to allocate one protected day for PAs to complete all the modules, in order to support study timings and avoid the Christmas holidays. Neither of the PAs interviewed from this LA said this was problematic, but in feedback at the Skills workshop there were strong feelings that it was too intensive to complete the modules in one day and that completing the modules as a group was impractical. This is not surprising as the modules were not designed to be viewed in a group, and we learned that some PAs drifted away and not all modules were covered in the designated day. This made it difficult to ascertain how many modules had been viewed by how many PAs in this LA. Views were generally mixed about the provision of the training online. Some liked the flexibility afforded by online modules, in respect of when they could watch them and at what pace. Others found the online delivery difficult. The quotes below illustrate the two opposing views about training timespan and the perceived benefits of interaction and reflection time:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;So just to have it a bit in a more of a bulk training maybe over a day or two rather than have it spread out how it was. And maybe how it was like the online and the face to face, I think that that worked really, really well because not a lot of us have time to go to these sessions, but we could do them in our own time. But yeah, I do think that we should have been able to dedicate two whole days to be able to do everything in one and make it more of an interactive workshop together, all of us PAs\u003c/em\u003e \u003cstrong\u003e\u0026quot; (LA 2, participant 50)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eQ: \u0026ldquo;I think the timing of it wasn\u0026rsquo;t great, because it was Christmas and it was crazy busy, and that I think put an additional pressure. So I feel that, as I\u0026rsquo;m sure my colleagues felt, we kind of felt we had to rush through it. Whereas I think, given more time and spread out over a longer period of time, so whether that be monthly or fortnightly, one of the modules, I think it would be a bit more powerful, you\u0026rsquo;d be able to take more in and reflect on it more. Whereas we were trying to squish everything into a day.\u0026rdquo; (\u003c/em\u003e \u003cstrong\u003eLA 2 participant 64)\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eThe evidence from the platform used to host the modules (NIHR LEARN) and from interviews and other discussions with PAs suggested that protected time to complete them was difficult to secure. There was a noticeable difference across the three local authorities in the interest and support from senior management. In one local authority the senior manager responsible was very active in not only reminding staff of the training and the study requirements, but in facilitating their completion of these. In another, the senior staff delegated responsibility for the study to the team leader of one of the intervention team, who did very little to support staff with either. The senior manager in the third was proactive, but over-stretched, and the local authority was facing some organisational challenges. In general, PAs in all three local authorities felt the training was \u0026lsquo;over-and-above\u0026rsquo; their already busy workloads, even in the agency with most management support.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003ePerceptions of the Content\u003c/h2\u003e\n \u003cp\u003eThe content of the training was generally well received. Of the 11 PAs who commented specifically on the usefulness of the modules five said they were all useful, with one PA pointing out that it was especially useful to them as it was their first year as a PA and another highlighting the structure of the modules with summary points as being very good. Unsurprisingly, different PAs identified different modules as being particularly useful to them, ranging from dental health (5 PAs), health service structure (3 PAs), through sexual health and relationships, mental health, drugs and trauma, and barriers to care leavers accessing health services all singled out by individual PAs. Some PAs selected more than one module topic. The general relevance of the modules to their work was confirmed in the webinars, and the few PAs who considered certain modules being less useful cited their existing knowledge and experiences as reasons for this. In one LA, PAs had already received training on trauma, so found this less useful.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;they\u0026apos;re all useful in some way because \u0026hellip;. you know when we first start, we have like during our induction period, we obviously focused on a lot of areas of people\u0026apos;s lives such as like housing and sort of like relationships and work and learning, things like that. But we don\u0026apos;t necessarily have anything that incorporates sort of health.\u0026quot;\u003c/em\u003e\u003cstrong\u003e(LA 2 Participant 54)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;But I think more the point that hit home with myself is that I wouldn\u0026apos;t have thought twice before, oh, do you see a dentist regularly? Are you going to an optician regularly?\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e(LA 3 Participant 6)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I came at it from someone who has been doing this kind of work for nearly ten years and it was a bit of a recap and actually a lot of it was quite basic stuff that yeah, we kind of knew anyway.\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e(LA 1 Participant 42)\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe skills workshops provided participants with an opportunity to discuss the research evidence on the correlates of effective helping relationships, and to practice core skills. They were overwhelmingly considered to be positive. The communication skills were appreciated, along with the chance to learn from colleagues. PAs welcomed the input of health professionals to answer questions about the health service and how to use them effectively.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Use of key words, being older my language perhaps is not up to date with current trends in what words to use, so that was helpful.\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e(LA 1 Participant 28)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot; the skills workshop \u0026hellip; tied up all of the online resources, and it was nice to be in part of a group to be able to talk about everybody\u0026apos;s thoughts and opinions on those online sessions as well. It was useful that the person hosting the skills was, I believe she said she was a psychologist, I believe, so I think that was really interesting because it showed us like the reasoning behind behaviours and things, and it just ties up everything really quite well\u0026quot;\u003c/em\u003e\u003cstrong\u003e(LA 2 Participant 50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThere was general agreement that the training would be useful for those new to the PA role. Discussions at webinars and the skills workshops suggested that those who felt they knew they content were not always as well-informed as their responses suggested. For example, in the Local Authority whose PAs most often asserted that they were already familiar with health issues it was evident that there was limited understanding of the longer-term impact of trauma.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e7. Acceptability of randomisation\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eRandomisation was viewed as acceptable by all three local authorities, and by the PAs who attended the first webinar Some PAs and managers were variously disappointed or relieved at being allocated to the control arm. In one local authority, two of the control PAs who were interviewed said they would have found it hard to fit additional things into their schedules, but in another local authority, four PAs said they were disappointed to be in the control as it meant they missed out on training they thought would benefit care leavers. One of these PAs said they ignored information from the study team because of this. For two other PAs in this LA, they were conflicted, feeling disappointed at not receiving the training but also happy about not having extra tasks to do too.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Yeah. I was a little bit disappointed, actually, because I always welcome any training, or any new learning. So, I was a little bit confused, I\u0026rsquo;d say, \u0026lsquo;What does that mean? What am I going to be doing, then?\u0026rsquo; And I was a bit like, \u0026lsquo;Oh. Why didn\u0026rsquo;t we get picked?\u0026rdquo; (\u003c/em\u003e\u003cstrong\u003eLA 3 Participant 21)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026apos;I think initially I was annoyed that I was missing out. But then, straight after that, I was, kind of, relieved, because I thought, \u0026lsquo;Where am I going to find the time to do it?\u0026rsquo; So, it was, kind of, a bit mixed, really.\u0026rdquo; (\u003c/em\u003e\u003cstrong\u003eLA 3, participant 16)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We\u0026apos;re so busy we haven\u0026apos;t had time to go, \u0026lsquo;Were you not? Are you not going to do that?\u0026rsquo; There\u0026apos;s so many other things going on for us, that this is, no offence, but this isn\u0026apos;t like a big thing that we\u0026apos;re dealing with, so it often gets sort of by the wayside just because we\u0026apos;re like, \u0026lsquo;Oh, I didn\u0026apos;t get selected, okay, crack on\u0026rdquo; (\u003c/em\u003e\u003cstrong\u003eLA 1 participant 39)\u003c/strong\u003e\u003c/p\u003e\n \u003c/div\u003e\u003cspan\u003e\n \u003cp\u003e8. Evidence of contamination across arms\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eThe control PAs interviewed were asked about contact with intervention team colleagues where the LIFT study may have been discussed; none was reported. A couple of PAs mentioned that they spent limited time in the office post pandemic and in two of the local authorities, teams were based in different locations so there would have been limited opportunities for contamination. One PA from the LA where teams were co-located moved from an intervention team to the control team after the training had been completed. The two control PAs interviewed from that local authority reported no discussion about the study with this PA, and one said, \u0026lsquo;There\u0026rsquo;s been no cross-fertilisation\u0026rsquo;!\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e9. Implementation fidelity and intervention cost\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eAll workshops (which were observed) covered the programme as set out in the manual. Whilst all participating intervention PAs engaged with the modules, we cannot be confident that all PAs completed all modules.\u003c/p\u003e\n \u003cp\u003eAt the end of the Skills Workshop intervention PAs were asked to share their SMART goals with their line managers in order to embed a focus on health within routine practice. Those PAs who attended the final session reported that their goals were generally achieved but we do not have information on the success or failure of PAs who did not attend this final session.\u003c/p\u003e\n \u003cp\u003eThe cost of the training programme for PAs is presented in Supplementary File 3 Table \u003cspan class=\"InternalRef\"\u003eS4\u003c/span\u003e. The greatest category requiring investment by LAs would be the protected time for staff to complete the training.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e10. Performance of candidate outcome measures and Estimate of the Intra-Cluster Correlation Coefficient\u003c/p\u003e\n \u003c/span\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e presents summary statistics for the standardised measures, with the baselines presented for those participants who at least partially completed one of the main follow-up assessments. The PEPPI10 was discontinued after the first follow-up to reduce participant burden and due to overlap with the Pearlin Mastery Scale. All CLS were invited to complete the Pearlin Mastery Scale at the final follow-up, with 50/71 (70%) doing so. The modest number of CLs participating in this feasibility study prevents any conclusions being drawn from changes in the mean values over time in the two groups. Furthermore, the modest number of PA teams resulted in very imprecise estimates of the ICCs (see Supplementary File 4, Table S16c).\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCompletion of interviews and standardised measures\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIntervention (46 CLs)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eComparison (25 CLs)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean (SD), N*\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean (SD), N*\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePerceived Efficacy in Patient-Physician Interactions Questionnaires\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline \u0026ndash; responding to follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.3 (12.0), 36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e38.5 (10.6), 21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFirst follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39.1 (10.5), 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36.9 (11.9), 16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePearlin Mastery Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline \u0026ndash; responding to follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.1 (3.5), 37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.8 (3.2), 22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFirst follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.8 (2.6), 23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.7 (4.3), 16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.6 (3.8), 31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.1 (3.7), 19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecovering Quality of Life (ReQoL-10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline \u0026ndash; responding to follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.3 (7.9), 23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.5 (3.5), 10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFirst follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25.5 (6.9), 15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.4 (8.2), 8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.2 (9.3), 22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.4 (10.1), 9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecovering Quality of Life (ReQoL-20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBaseline \u0026ndash; responding to follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e52.3 (15.3), 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.7 (5.7), 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFirst follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51.3 (14.1), 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56.7 (14.8), 3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinal follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58.1 (12.6), 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e63.5 (16.0), 4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e*N\u0026thinsp;=\u0026thinsp;number responding, SD\u0026thinsp;=\u0026thinsp;standard deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis feasibility study suggests that the training intervention developed for PAs was broadly acceptable, and that it is feasible to recruit and retain both PAs and CLs in a randomised controlled trial within children’s social care. A large majority (83%) of eligible PAs agreed to participate in the trial (63 out of 76), and we recruited 71 CLs, eleven more than our target. At 73% at 48 weeks, the retention of CLs was good, indicating that the key procedural elements needed to form part of an experimental evaluation of the training’s effectiveness are feasible. Recruitment of CLs by the study team, rather than via PAs, would help ensure a representative sample of CLs, and preliminary work with team leaders might help to embed learning in practice.\u0026nbsp;Because it proved not to be feasible to deploy the peer researchers in the study, it was not possible to blind all outcome assessors because we did not have alternate resources. However, the study indicates that blinding of outcome assessors is, in principle, feasible. Whilst some of the questions included in the final interviews with PAs were ‘arm-specific’, these would not form part of a pragmatic trial. The data suggest a potential source of selection bias, in that from a mean caseload of 18, we recruited only one or two CLs from most PAs to the study, and none from close to one half.\u003c/p\u003e\n\u003cp\u003eIn relation to our secondary objectives, randomisation presented no problems and the feedback gathered from PAs and CLs suggest that the data burden was acceptable and importantly, that we were not asking too much of CLs. There was no evidence of contamination between the two arms of the trial.\u003c/p\u003e\n\u003cp\u003eThe key problem to emerge related to the outcome measures chosen and their performance. It is very difficult to identify one outcome measure that can adequately capture the potentially diverse range of effects of the intervention across a large group of CLs with very different health issues and yet be sensitive to the specific effect in each individual. A core outcome set for CLs would be helpful, but our experience suggests it would be challenging to establish.\u003c/p\u003e\n\u003cp\u003eWhilst the questions to CLs were acceptable, we dropped one at first follow-up because of an apparent ceiling effect and to minimise some apparent overlap between questions on the PEPPI-10 and our open ended questions about their relationships with their personal advisors. The remaining measures appeared not to be sufficiently sensitive to discriminate between the two groups.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eAs is frequently the case for a feasibility study for a cluster RCT, the key limitation was the limited number of sites and of PA teams that could be involved. Consequently our estimates of the ICCs were not usefully precise.\u003c/p\u003e\n\u003ch3\u003eGeneralisability\u003c/h3\u003e\n\u003cp\u003eWhilst participating sites are not typical of all LAs (no London boroughs or metropolitan councils, or rural sites), the baseline data from this study are likely to be generalisable to other areas. The three LAs who participated in this study included two large counties, and one large city council. All had different organisational structures, which required flexibility in planning the delivery of the training. In 2022, when recruitment commenced, One was in contact with 166 care leavers aged 17-18 and 332 care leavers aged 19-21 (99% and 91% respectively). In another, the numbers were 82 and 252 (93% and 97%) and in the third they were 129 and 305 (100% and 97%). Nationally in that year, LAs were in touch with 94% of care leavers aged 17-18 and 92% of those aged 19-21. The Principal Investigator had previously worked with one LA on another trial, but the relationships with the other two were new, and none of the teams involved had previously participated in a randomised trial.\u003c/p\u003e\n\u003cp\u003eThe skills workshops served to highlight both the very challenging nature of the personal advisor role, and the limited knowledge that most have of ‘what works’ in engaging young people in sensitive discussions in general, and health issues in particular. Typical skills included asking open ended questions, asking specifically about health issues or concerns that personal advisors might have about a particular young people, how to convey key relationships skills such as empathy, warmth and genuineness, and when and how to use skills such as humour or limited self-disclosure.(55) Although the three sites were located in the South West and the East Midlands, in respect of the training intervention, the training that PAs were most likely to have received \u003cem\u003eoutside\u003c/em\u003e of the trial was training in trauma-informed practice, reflecting a larger trend to make such training available to the children’s social care workforce, though evidence of a good understanding of the impact of trauma was not very evident. Broader training on health issues is not available.\u003c/p\u003e\n\u003ch5\u003eInterpretation\u003c/h5\u003e\n\u003cp\u003eThe CLs we recruited were mainly female, and mainly white British, despite there being sizeable populations of minoritised ethnic groups in two of the three local authorities. Data on the ethnicity of CLs is difficult to obtain, but in Bristol, for example, 10% of CLs were unaccompanied asylum-seeking young people, but the project only recruited one. In Nottinghamshire in 2024, 9.9% of care leavers aged 18-21 identified as ‘mixed race’, 1.4% as Black and 2.4% as Asian, but the study recruited very few minoritised participants,\u003c/p\u003e\n\u003cp\u003eIn respect of gender and ethnicity the CLs we recruited were not representative of CLs nationally. Recruitment via social media and in person sessions (with researchers) attracted more interest from a wider range of care leavers in terms of gender and ethnicity, and such approaches are likely to enhance recruitment in future trials. Recruitment strategies that enabled details of the study to be circulated directly to care leavers would also improve recruitment, as our reliance on professionals within the agencies was somewhat problematic, particularly in the LA lacking strong leadership for the study. Recruiting CLs from the caseloads of all participating PAs would assist in securing evidence of the impact of training in a future, pragmatic trial, or in any trial interested in the impact of changing staff knowledge, skills or practice methods.\u003c/p\u003e\n\u003cp\u003eIn respect of data collection, we experienced few problems in maintaining contact with care leavers. The ‘dip’ in response rate at the first follow-up was largely attributable to the realities of seeking to use peer-researchers. We recruited and trained two groups of peer researchers to conduct the follow up interviews, and to text care leavers to gather the two-monthly Health Service Use data. Implementation proved problematic, with peer researchers often unable to conduct interviews, most often for logistical reasons e.g. our requests clashing with essay deadlines for those studying in higher education, but sometimes for personal reasons e.g. poor mental health or family difficulties. Our reflection is that it is not feasible to expect peer researchers (or any other researchers) to work on what is, effectively, a ‘zero hours contract’. This view was endorsed by the TSC, whose members included those with many years’ experience of working with CLs and those in care. They recognised the excellent input of care-experienced young adults on the Advisory Committee throughout the study, but agreed with the research team that seeking to recruit peer researchers for what is, effectively, an unpredictable schedule of interviews on such a basis is not feasible, however well supported and trained they are (and were) by CORAM staff and those on the study team.\u003c/p\u003e\n\u003cp\u003eRecruiting researchers with care experience as part of the core team or conducting the interviews ‘in house’ is more feasible. The latter worked well, as evidence by the upturn in response rates once the team took this decision.\u003c/p\u003e\n\u003cp\u003eThe completion of follow-up interviews by PAs was reasonable in two of the three LAs at 58% and 63%, particularly as a number of staff in these authorities had extended periods of leave of three months (4 and 3 respectively). In these authorities, there was active promotion and management of the training and compliance with the study by a senior manager. Such support and leadership were not available in the third and we believe this was a major factor in the poorer participation in follow-up interviews by PAs (26%) and in generally more negative attitudes towards the training provided.\u003c/p\u003e\n\u003cp\u003eThe qualitative data from PAs confirmed the relevance of the content of the training modules and the skills workshop. Those who felt they were familiar with some of the content said it was a ‘good refresher’, and some of the content addressed issues that had received little attention, such as oral health, the importance of embedding ‘health in every contact’ and of asking open ended questions.\u003c/p\u003e\n\u003ch5\u003eImplications for progression\u003c/h5\u003e\n\u003cp\u003eWe discussed the results with our TSC and with a group of care-experienced young people. The TSC considered the trial to be a success in respect of the study aims and suggested that a pragmatic trial was feasible, with the caveat of the need to identify an adequate outcome measure or measures.\u0026nbsp;The study highlighted minor changes to the methods that would increase the likelihood of a successful future trial, such as ensuring the involvement of senior social care leadership, using social media and recruitment methods that enabled the team to contact care leavers more directly, though this might have cost implications. The study also pointed to minor changes that might facilitate more effective engagement with the content of the modules, such as shortening some of the longer modules and adding questionnaires at the end of each module to ensure those working through them adequately understood the materials. The poor follow-up questionnaire completion by PAs, along with some baseline responses missing, may indicate, respectively, ‘survey fatigue’ within the participating local authorities or ambivalence by some staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome members of the TSC were unconvinced of the appropriateness of pursuing a future trial for a range of reasons. The qualitative feedback from study participants and the data gathered from the measures provided no indication that the training had benefited those in the intervention arm compared with those in the control arm. Others considered that the evident heterogeneity amongst PAs in their levels of knowledge and skills, combined with a general lack of health literacy amongst many merited consideration being given to making the training available in the absence of further evaluation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTaken together, this study demonstrates the feasibility of conducting a randomised controlled trial in children\u0026rsquo;s social care within the UK. An evaluation of the LIFT intervention specifically would need an outcome measure able to capture the diverse potential benefits across the community of CLs, and the participation of those PAs and CLs with the greatest potential to benefit. A future trial would also need to consider implementation costs (including pre-implementation and planning, adaptation, intervention and sustainment) in order to understand the budget impact. Building on the intervention costs and valuation of resource consequences reported herein, further economic methods could consider a policy cost-effectiveness approach or a value of information and value of implementation approach, dependent on local decision-makers\u0026rsquo; needs. The TSC raised broader concerns which need to be considered alongside the results of this study when deciding whether to proceed to a full trial evaluation of the LIFT intervention.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe study team would like to convey our appreciation to all those Personal Advisors and Care Leavers who participated in the study, and to those in the local authorities who showed leadership in facilitating the study, who encouraged their staff to participate and made time available for them to take part in the study and, for those in the intervention group, the training.\u003c/p\u003e\n\u003ch3\u003eExperts by experience\u003c/h3\u003e\n\u003cp\u003eWe would like to express our gratitude to the care experienced consultant advisors who helped us both to develop the training and to deliver the study. Particular thanks to Peer Advisors Thuy-Ly Chambers, Kiri Scamp, and Sarah Beth Harper.\u003c/p\u003e\n\u003ch3\u003eLocal authorities\u003c/h3\u003e\n\u003cp\u003eGloucestershire County Council, Bristol City Council and Nottinghamshire County Council.\u003c/p\u003e\n\u003ch3\u003eTrial Steering Committee\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDr Kristin Liabo (Chair) University of Exeter; Professor Mike Clarke, Queens University, Belfast; Professor Helen Roberts, Institute of Child Health, University College, London; Dame Annie Hudson, Chair of the Child Safeguarding Practice Review Panel; Dr Jane\u0026nbsp;Schulte, Formerly Medical Advisor, CCS Adoption, Christa Laird, Formerly Social worker and Training and Development Manager, Oxfordshire Social Services.\u003c/p\u003e\n\u003ch3\u003eTrial Management Group\u003c/h3\u003e\n\u003cp\u003eShelley Caldwell, North Somerset Council; Linda Briheim, Coram Voice; Thuy Lee-Chambers, Coram Voice; Sarah Beth Harber, Coram Voice; Kiri Scamp, Coram Voice; Jenny Humphreys, Coram Voice; Shelley Reed, Coram Voice), Julie Selwyn, Rees Centre, University of Oxford\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eGM designed and oversaw the study, with input from PL, JT, CM and FL. GM, JH and LC designed and carried out the process evaluation, with advice from PL, and FL designed and led the health economics activities. JT, JH and LC managed the study. CM designed and conducted the statistical components of the study. All authors contributed to this paper and have consented to publication.\u003c/p\u003e\n\u003ch3\u003eFunding\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe study was funded by an NIHR (National Institute of Health and Care Research) Health Services and Delivery Research Programme 17/108/06.\u003c/p\u003e\n\u003ch3\u003eData availability\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eData will be available on reasonable request. The trial protocol is available from the first author.\u003c/p\u003e\n\u003ch4\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eApproved 25/03/2023, School for Policy Studies Research Ethics Committee, University of Bristol, Reference number: SPSREC21-22/227\u003c/p\u003e\n\u003ch4\u003eConsent for publication\u003c/h4\u003e\n\u003cp\u003eN/A.\u003c/p\u003e\n\u003ch4\u003eCompeting interests\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAshton-Key M, Jorge E. Does providing social services with information and advice on immunisation status of \u0026ldquo;looked after children\u0026rdquo; improve uptake? Archives of disease in childhood. 2003;88(4):299-301.\u003c/li\u003e\n\u003cli\u003eWalton S, Bedford H. Immunization of looked‐after children and young people: a review of the literature. 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Pregnancy risk among older youth transitioning out of foster care. Children and Youth Services Review. 2013;35(10):1760-5.\u003c/li\u003e\n\u003cli\u003eCraine N, Midgley C, Zou L, Evans H, Whitaker R, Lyons M. Elevated teenage conception risk amongst looked after children; a national audit. Public Health. 2014;128(7):668-70.\u003c/li\u003e\n\u003cli\u003eBoonstra HD. Teen pregnancy among young women in foster care: A primer. Guttmacher Policy Review. 2011;14(2):8-19.\u003c/li\u003e\n\u003cli\u003eNational Audit Office. Care leavers\u0026rsquo; transitions to adulthood: report by the Comptroller and Auditor General. London: NAO; 2015.\u003c/li\u003e\n\u003cli\u003eBotchway SK, Quigley MA, Gray R. Pregnancy-associated outcomes in women who spent some of their childhood looked after by local authorities: findings from the UK Millennium Cohort Study. BMJ open. 2014;4(12):e005468.\u003c/li\u003e\n\u003cli\u003eBublitz MH, Rodriguez D, Gobin AP, Waldemore M, Magee S, Stroud LR. 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London2016.\u003c/li\u003e\n\u003cli\u003eMezey G, Robinson F, Campbell R, Gillard S, Macdonald G, Meyer D, et al. Challenges to undertaking randomised trials with looked after children in social care settings. Trials. 2015;16(1):206.\u003c/li\u003e\n\u003cli\u003eMoody G, Brookes-Howell L, Cannings-John R, Channon S, Coulman E, Rees A, et al. What are the challenges when recruiting to a trial in children\u0026rsquo;s social care? A qualitative evaluation of a trial of foster carer training. Trials. 2021;22:1-12.\u003c/li\u003e\n\u003cli\u003eLuke N, Banerjee R, Dunn V, Douglas N, Kelly \u0026Aacute;, Trivedi H, et al. Well-being package for foster carers and teachers of looked-after children aged 8 to 11 years: the STrAWB feasibility RCT. Public Health Research. 2025.\u003c/li\u003e\n\u003cli\u003ePersonal well-being in the UK: April 2020 to March 2021: Estimates of life satisfaction, feeling that the things done in life are worthwhile, happiness and anxiety at the UK, country, regional, county and local authority level. [press release]. London, UK: Office for National Statistics2021.\u003c/li\u003e\n\u003cli\u003eStatistics OfN. Census 2021: Health, disability and unpaid care. 2021.\u003c/li\u003e\n\u003cli\u003eMaly R, Frank J, Marshall G, DiMatteo M, Reuben D. Perceived Efficacy in Patient-Physician Interactions Questionnaire. Measurement tools in patient education. 2003:53-5.\u003c/li\u003e\n\u003cli\u003ePearlin LI, Schooler C. The structure of coping. Journal of health and social behavior. 1978:2-21.\u003c/li\u003e\n\u003cli\u003eKreimeier S, Greiner W. EQ-5D-Y as a health-related quality of life instrument for children and adolescents: the instrument\u0026apos;s characteristics, development, current use, and challenges of developing its value set. Value in Health. 2019;22(1):31-7.\u003c/li\u003e\n\u003cli\u003eKeetharuth AD, Brazier J, Connell J, Bjorner JB, Carlton J, Buck ET, et al. Recovering Quality of Life (ReQoL): a new generic self-reported outcome measure for use with people experiencing mental health difficulties. The British Journal of Psychiatry. 2018;212(1):42-9.\u003c/li\u003e\n\u003cli\u003eKeetharuth A, Brazier J, Connell J, Carlton J, Taylor Buck E, Ricketts T, et al. Development and validation of the Recovering Quality of Life (ReQoL) outcome measures. 2024.\u003c/li\u003e\n\u003cli\u003eTruax CB, Carkhuff RR. Towards effective counseling and psychotherapy: training and practice. Chicago: Aldine; 1967.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cluster randomised trial, feasibility trial, care leavers, personal advisors, health","lastPublishedDoi":"10.21203/rs.3.rs-8000798/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8000798/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInequalities in health amongst care-experienced young people span all aspects of health, including mental health and wellbeing. We developed an intervention to better equip Personal Advisors (staff with statutory responsibility for supporting Care Leavers) to address a range of health issues. The study aimed to assess the acceptability of the intervention and the feasibility of conducting a definitive cluster randomised trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis 24-month study took place in three local authorities (LAs) between 2022 and 2024. Two LAs were in the South West of England, the third was in the East Midlands. Two of the three Personal Advisor teams in each LA were randomised to receive the training, which comprised six online modules and a one-day skills workshop facilitated by health professionals. Study participation was voluntary but all staff in the intervention arm were expected to complete the training. Control teams received no training. Our objectives were to evaluate the feasibility of recruitment and retention of both Personal Advisors (PAs) and Care leavers (CLs), data collection (by peer researcher and research staff), the acceptability and cost of the intervention and the general demands of the study. We conducted qualitative interviews with PAs and CLs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe recruited 63 of 76 eligible PAs and 71 CLs. 52 CLs (73%) completed the final follow up interview. CLs were typically female, white with a mean age of 19 years. Just over half were not in education, employment, or training. The intervention was broadly acceptable, but some PAs reported difficulties in finding the time to complete the modules, despite a commitment by managers of protected time to do so. Some PAs said they were already familiar with some module content. The demands of the trial were generally judged to be acceptable to CLs and to PAs. Delays incurred by the REDCap team meant that we had to stagger the recruitment of PAs and CLs. This extended the number of requests to LA staff, which some found irksome. Plans to use peer researchers had to be abandoned for logistical reasons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results demonstrate the feasibility of conducting a cluster randomised trial in children’s social care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e ISRCTN, ISRCTN11518804. Registered 13 January 2023, https://www.isrctn.com/ISRCTN11518804\u003c/p\u003e","manuscriptTitle":"Improving Health Outcomes for Care Leavers: the Life in Transition (LIFT) cluster-randomised feasibility trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 04:22:02","doi":"10.21203/rs.3.rs-8000798/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-01-15T20:02:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-24T07:08:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pilot and Feasibility Studies","date":"2025-11-20T13:25:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dd2009e8-e51f-4cc8-91a3-eb90337c64cf","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-21T04:22:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-21 04:22:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8000798","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8000798","identity":"rs-8000798","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}