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Journal Cover The Lancet
   [1180 followers]  Follow    
   Full-text available via subscription Subscription journal
     ISSN (Print) 0140-6736 - ISSN (Online) 1474-547X
     Published by Elsevier Homepage  [2571 journals]   [SJR: 7.074]   [H-I: 477]
  • Implementation of a fire-prevention injury prevention briefing in
           children's centres: a multicentre cluster-randomised controlled trial
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Toity Deave , Adrian Hawkins , Arun Kumar , Nicola Cooper , Trudy Goodenough , Michael Watson , Carol Coupland , Gosia Majsak-Newman , Lisa Mcdaid , Joanne Ablewhite , Rose Clacy , Elaine McColl , Richard Reading , Mike Hayes , Denise Kendrick
      Background England has high morbidity and mortality from house fires, with steep social gradients for child deaths: 106 people were admitted to hospital in 2012–13, and 44 deaths between 2008 and 2012 were in children under 5 years old. We developed an evidence-based fire-prevention intervention for use in children's centres comprising an injury prevention briefing (IPB), training, and facilitation for IPB implementation. Methods We conducted a multicentre cluster-randomised controlled trial, with a nested qualitative study, in four English study sites. Parents who were at least 16 years old with a child younger than 3 years were recruited from children's centres in disadvantaged areas. Once 30 parent participants were recruited at each centre, centres were stratified by trial site, randomly allocated within strata to one of three arms by an independent statistician using randomisation algorithm in Stata with permuted block randomisation and block size of three: IPB plus facilitation (IPB+), IPB only, and usual care (control). Training (month 0) and facilitation were provided for centres allocated IPB+ at months 1, 3, and 8. Both intervention arms completed follow-up interviews at 12 months. The primary outcome was the proportion of families reporting a fire-escape plan. 11 centres per arm were required to detect an absolute difference of 20% or more in families with fire-escape plans in either intervention arm compared with control (80% power, 5% significance level, intraclass correlation (ICC)=0·05), assuming responses from 20 families per centre. Treatment arms were compared by use of multilevel models to account for clustering by centre. Ethics approval was given by Derbyshire ethics committee (11/EM/0011). Written informed consent was obtained from individual parents and children's centres. This trial is registered with ClinicalTrials.gov, NCT01452191. Findings 1112 parents at 36 centres were recruited (373 IPB+, 369 IPB only, 370 control). At 12 months 751 (68%) parents (241 IPB+, 252 IPB only, 258 control) were followed up. Possession of a fire-escape plan was reported by 120 (51%) IPB+ participants, 108 (44%) IPB only, and 119 (47%) controls. There was no significant effect on family possession of fire-escape plans (IPB+ vs control odds ratio 1·41, 95% CI 0·91–2·20; IPB only vs control 0·93, 0·58–1·49 [ICC=0·003]). No adverse events were reported. Interpretation The IPB, training, and facilitation did not increase parents' possession of fire-escape plans. Both the difficulties faced by children's centres in delivering the intervention to participating families and the secondary outcomes help to explain this outcome. Further research is required to explore both enhancement of penetration of interventions, such as the IPB, to disadvantaged communities and what single item questions about fire escape plans actually measure. Funding National Institute for Health Research under its Programme Grants for Applied Research programme (RP-PG-0407-10231).


      PubDate: 2014-11-21T03:03:31Z
       
  • Successful ageing, education, and functional trajectories in later life: a
           longitudinal latent variable modelling analysis
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Theodore D Cosco , Graciela Muniz , Blossom C M Stephan , Carol Brayne
      Background The MRC Cognitive Function and Ageing Study (MRC CFAS) is a longitudinal population-based cohort of British adults aged 65 years and older. This study assessed associations between education and longitudinal successful ageing trajectories. Methods A representative sample of individuals aged 65 years or more, from five UK sites, was eligible for inclusion. Study participants were individuals (n=1141) from the 2-year, 4-year, and 6-year MRC CFAS follow-up data collection periods. Mean age was 76·4 years (SD 6·5), and 723 (63·4%) were women. The primary outcome was an index consisting of items identified by systematic reviews of operational definitions and lay perspectives of successful ageing: self-reported psychological and social components (ie, perspective, engagement, and self-rated health) and physiological components (ie, cognitive and physical functioning). Growth mixture modelling, a person-centred longitudinal latent variable modelling procedure, was used to identify heterogeneous functional trajectories across three MRC CFAS periods (data version 9.0). Models were estimated using maximum likelihood, with missing observations assumed to be missing at random. Unadjusted and adjusted (for age, sex, and socioeconomic status [SES]) logistic regression was used to assess the association between years in full-time education (≤9, 10–11, ≥12) and functional trajectory. Findings A three-class model provided the best fit, capturing a high functioning trajectory (HFT), moderate functioning trajectory (MFT), and low functioning trajectory (LFT). Individuals in the HFT were significantly younger, and consisted of significantly more men and of fewer individuals with low SES, than individuals in the MFT (p<0·0001) and LFT (p<0·0001). Logistic regression models adjusted for age, sex, and SES indicated that individuals in the HFT spent significantly more years in full-time education than did individuals in the MFT (odds ratio 1·68, 95% CI 1·18–2·38, p=0·004) and LFT (1·59, 1·07–2·36, p=0·02), as did unadjusted models (1·53, 1·16–2·03, p=0·003, vs 1·75, 1·30–2·36, p<0·0001). Interpretation Education is independently associated with a high psychosocial-physiological functioning trajectory—ie, successful ageing. These results provide evidence for the long-term, beneficial effects of education in a sample of older British adults, with implications for policy, such as promotion of continued education, and for public health, such as fostering lifelong wellbeing. Funding Medical Research Council and Department of Health (grant no G9901400).


      PubDate: 2014-11-21T03:03:31Z
       
  • Are financial incentives for breastfeeding feasible in the UK' A mixed
           methods field study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Clare Relton , Barbara Whelan , Mark Strong , Kate Thomas , Heather Whitford , Elaine Scott , Patrice van Cleemput
      Background The UK has one of the lowest breastfeeding rates (duration and exclusivity) in the world. Moreover, breastfeeding is strongly socially patterned, with young women in areas of high deprivation being less likely to breastfeed than women in areas of low deprivation. This study tested the feasibility of a financial incentive intervention to increase breastfeeding in areas with 6–8 week breastfeeding rates of 40% or less. Methods The intervention was the offer of a structured financial incentive scheme to women with babies aged up to 6 months old. If women were breastfeeding their baby, they could claim vouchers, at five different timepoints—ie, when their baby reached 2 days, 10 days, 6 weeks, 3 months, and 6 months old. Breastfeeding was verified by signed statements from the mother and health-care professional. Vouchers were for supermarkets and high street shops, to the value of £40, up to a maximum of £200. Starting in November, 2013, the scheme was offered to women with babies born during a 16-week period resident in three neighbourhoods in Derbyshire and South Yorkshire, UK, all of whom had historically persistent low 6–8 week breastfeeding rates, ranging from 21% to 29%. The feasibility (acceptability and deliverability) of the incentive scheme and the study design to key stakeholder groups was assessed with quantitative and qualitative methods, in advance of undertaking a full randomised controlled trial. 36 health-care providers and 18 women gave semi-structured interviews. Findings Relevant approvals for the study were obtained. Women learnt about the scheme from their midwife or the media (print, radio, social media), or both. Of a total of 108 women eligible for the scheme, 58 (53·7%) joined the scheme, 48 (44·4%) claimed 2-day vouchers, 45 (41·7%) claimed 10-day vouchers, and 37 (34·3%) claimed 6–8 week vouchers. 3-month and 6-month data are still accruing. 53 health-care providers cosigned claim forms. Satisfaction with the scheme (including the method used to verify breastfeeding) was high among both mothers and health-care staff participating in the scheme. Interpretation The scheme was both deliverable and acceptable to mothers and health-care staff in this field study. The scheme was extended (and will continue until at least December, 2014) in all three areas. A randomised controlled trial testing the effectiveness of the scheme is now planned. Funding Medical Research Council National Prevention Research Initiative (MR/J000434/1).


      PubDate: 2014-11-21T03:03:31Z
       
  • Use of seemingly unrelated equations to assess changes in dietary
           behaviours during the UK's economic crisis
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Michele Cecchini
      Background In 2008, the world economy entered one of the most severe crises ever. Standards of living fell for large parts of the population in many countries. For example, UK families cut their food expenditure by 8·5%. The aim of this study was to assess whether the economic crisis was associated with any dietary change in the UK and other member countries of the Organisation for Economic Co-operation and Development (OECD). Methods A seemingly unrelated regression (SUR) model with random effect estimators was used on a panel dataset that included data between 1999 and 2013 for 21 OECD countries. The dataset included statistics from Euromonitor-Passport, OECD, World Bank, and Eurostat. The three variables of interest were purchase of fruit and vegetables, snack-bars, and snacks. Negative growth in gross domestic product (ie, economic crisis) was the explanatory variable of interest. Foodstuff-specific inflation rates and other key socioeconomic variables (eg, population age) were also included. Compared with standard statistical approaches, SUR models provide more efficient performances when dependent variables can be substituted (eg, fruit and vegetables, snack-bars, and snacks). Findings People living in countries affected by the economic crisis decreased their consumption of fruit and vegetables by 3·64 kg per head per year (95% CI −6·65 to −0·64, p=0·017) which is about one portion per week. At the same time, people slightly increased their consumption of snack-bars (22·6 g per head per year, 95% CI 1·5 to 43·8, p=0·036) and snacks (40·2, −50·5 to 130·9; p=0·385). In the UK, given the levels of consumption of these products, the above mentioned variations indicate that the economic crisis was associated with a 3·5% decrease in purchase of fruit and vegetables and an increased purchase of snack-bars (3·5%) and snacks (0·5%). Interpretation The findings of this study support the hypothesis that tighter food budgets might have led consumers to switch to lower-priced (per calorie) and less healthy food. The economic crisis might have therefore contributed to a further growth in obesity and related chronic diseases. Previous studies suggest that small effects at the population level can mask substantial inequalities across different socioeconomic groups. This study pioneers, in the field of public health, the use of an advanced econometric approach applied to a market information database. Funding This project is partly funded through regular contributions from OECD member countries.


      PubDate: 2014-11-21T03:03:31Z
       
  • The depth and breadth of public health science in the UK
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Richard Horton



      PubDate: 2014-11-21T03:03:31Z
       
  • An audacious goal: the elimination of schistosomiasis in our lifetime
           through mass drug administration
    • Abstract: Publication date: Available online 20 November 2014
      Source:The Lancet
      Author(s): Allen G P Ross , Remigio M Olveda , Yuesheng Li



      PubDate: 2014-11-21T03:03:31Z
       
  • Financial incentives for smoking cessation during pregnancy: a randomised
           controlled trial
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): David Tappin , Linda Bauld , David Purves , Kathleen Boyd , Lesley Sinclair , Susan MacAskill , Jennifer McKell , Brenda Friel , Alex McConnachie , Linda de Caestecker , Carol Tannahill , Andrew Radley , Tim Coleman
      Background In the UK, smoking during pregnancy kills 4000 babies annually and costs an extra £20–90 million for pregnancy and infant care. Only 5–10% of pregnant smokers quit when offered current interventions. We aimed to assess efficacy, cost-effectiveness, and acceptability of adding £400 of shopping vouchers to routine pregnancy smoking cessation services. Methods This study was a phase 2, single-centre, single-blinded, parallel-group individually randomised controlled superiority trial with qualitative and health economic components. Participants were self-reported pregnant smokers referred to Stop Smoking Services between Dec 15, 2011, and Feb 28, 2013, in Greater Glasgow and Clyde, Scotland. Randomisation, with allocation concealed from staff and participants, was by computer generated permuted blocks of four. 306 participants were randomised to routine care and 306 to the intervention (routine care plus incentives), giving 90% power to detect an increase in smoking cessation from 4·0% in women in the control group to 11·4% in women given incentives. Assessors of the primary outcome were masked to allocation. Women in both groups were offered routine care—namely, the offer of face-to-face contact to set a quit date, 10 weeks' free nicotine replacement therapy, and support calls weekly for 4 weeks. In addition, women in the intervention group were offered £50 in vouchers for setting a quit date, £50 if carbon monoxide confirmed smoking cessation after 4 weeks, £100 after 12 weeks, and £200 in late pregnancy (34–38 weeks' gestation). The primary outcome, analysed by intention to treat, was self-report of quitting in late pregnancy corroborated by cotinine in saliva (<14·2 ng/mL) or urine (<44·7 ng/mL). Cost-benefit analysis used routine and trial derived data. Ethics approval supported telephone consent. This trial is registered with Current Controlled Trials, ISRCTN87508788. Findings Significantly more smokers who were offered incentives quit than did controls (69/306 [23%] vs 26/303 [9%], 95% CI 8·3–19·5). Three control participants opted out. The relative risk of smoking in late pregnancy was 0·85 (95% CI 0·79–0·91). No harms were reported, and incentives were acceptable to clients and health workers. Short-term incremental cost per quitter was £1127 and longer-term cost per quality-adjusted life year gained was £482. Interpretation This trial provides evidence for the efficacy and cost-effectiveness of financial incentives, which must now be tested in other centres and with varied cessation services. Funding Chief Scientist Office of the Scottish Government, Glasgow Centre for Population Health, NHS Greater Glasgow and Clyde Endowments, and Yorkhill Children's Charity.


      PubDate: 2014-11-21T03:03:31Z
       
  • Towards enhanced community genetic literacy among a minority ethnic
           community: a participatory action research project
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Sarah Salway , Parveen Ali , Saima Ahmed
      Background Infant mortality is a key public health outcome showing substantial socioeconomic and ethnic inequalities in the UK. The UK Pakistani population has an infant mortality rate of over nine per 1000 livebirths, more than twice that for the population as a whole. Increased risk is partly attributable to rare autosomal recessive genetic disorders linked to the practice of customary consanguineous marriage. WHO recommends community-level action to raise genetic literacy combined with enhanced genetics services. However, UK interventions are in their infancy, with varied local initiatives and no national response. A combination of a valued social practice affecting marginalised communities, complicated patterns of risk, and low professional awareness, makes this a complex and contentious issue. Indeed, some previous intervention has generated considerable backlash. This study in Sheffield, a northern English city, aimed to develop a community-level genetic literacy intervention that would be sensitive and responsive to local information needs. Methods A participatory approach was used, drawing on a user-centred design and engaging local people as coresearchers. Two phases of insight gathering made use of group discussions, interviews, and participatory exercises to describe current understanding, gaps in knowledge, and trusted networks of communication. A series of testing-and-refinement cycles were then undertaken to coproduce a set of communication materials tailored to subgroups, with materials being tested for acceptability, appeal, and comprehension. Findings Six local people were trained as coresearchers. Over 200 people participated in the insight and testing work. Information needs and preferred communication channels varied widely, confirming population heterogeneity and diverse perspectives to the issue. Despite some resistance, there was strong demand for information and willingness to discuss the topic. Conveying accurate and consistent information was challenging, as was meeting differing demands for detail within generic materials. Key areas of confusion and mistrust were addressed. Narrative, real life audio (for local radio) and video (for social media) were recommended and developed, supported by factual information in leaflet and website form, and contained links to religious resources plus genetics services. Interpretation Development of appropriate community-level genetic literacy interventions can be achieved through participatory action research. Evaluative work is now needed to assess the effect on knowledge and service uptake. Funding Genetics Disorders UK funded the study. SS is a Senior Research Fellow funded by the National Institute for Health Research (NIHR) School for Public Health Research. Preparatory work was funded by NIHR Collaboration for Leadership in Applied Health Research & Care for South Yorkshire.


      PubDate: 2014-11-21T03:03:31Z
       
  • Does a complex intervention by primary care nurses increase walking in
           older people' Outcomes at 3 and 12 months in the PACE-Lift (Pedometer
           Accelerometer Consultation Evaluation-Lift) cluster-randomised controlled
           trial
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Tess Harris , Sally M Kerry , Christina R Victor , Ulf Ekelund , Alison Woodcock , Steve Iliffe , Peter H Whincup , Carole Beighton , Michael Ussher , Elizabeth Limb , Lee David , Debbie Brewin , Fredrika Adams , Annabelle Rogers , Derek G Cook
      Background Walking is the commonest physical activity done by older people. Intensity can be light if strolling, and moderate if brisker. We assessed whether a primary care nurse-delivered complex intervention increased walking. Methods Our study was a parallel two-arm cluster-randomised trial, randomised by household, by researcher using an internet randomisation service. 988 people aged 60–75 years, with no contraindications to increasing their walking, randomly selected from three UK general practices, were invited to participate. 298 people from 250 households were randomised to intervention (150 individuals) or usual care control group (148 individuals). During 3 months, intervention participants received four consultations from their own practice nurse about their physical activity, incorporating behaviour change techniques, feedback on step-counts as measured by pedometer and intensity of physical activity as measured by accelerometer, and an individual physical activity diary and plan. Outcomes were accelerometer-assessed change in average daily step counts over 7 days (primary outcome) and average time spent in physical activity of moderate-to-vigorous intensity weekly (secondary outcome) between baseline, 3 months, and 12 months. Adverse events were recorded by self-administered questionnaire. Assessors were not masked to group allocation. Analysis was by intention to treat, controlling for household clustering (intraclass correlation coefficient=0·004 at 3 months, 0·16 at 12 months). This trial is registered with Current Controlled Trials, ISRCTN42122561. Findings Outcome data were available for 280 (94%) individuals. Mean baseline average daily step-count was 7388 (SD 2218) in the intervention group and 7453 (2463) in the control group. At 3 months both average daily step-counts and average weekly moderate-to-vigorous physical activity increased significantly more in the intervention than in the control group by 1037 steps per day (95% CI 513–1560) and 66 min per week (36–96), respectively. At 12 months the corresponding differences were 609 (104–1115) and 40 (10–70). Differences in adverse events between intervention and control groups were not significant at either 3 months or 12 months (−4% [95% CI −15 to 7] vs −1% [–13 to 11], respectively). Interpretation In the PACE-Lift trial, both step-counts and moderate-to-vigorous physical activity increased in people aged 60–75 years at 3 and 12 months. To our knowledge, this is the first trial in older people to show objective increases in moderate-to-vigorous physical activity, and it highlights the value of both accelerometry physical activity assessment and primary care as a setting for phyisical activity interventions. If these differences in physical activity are sustained they should lead to important differences in health outcomes. Funding National Institute for Health Research Research for Patient Benefit Programme.


      PubDate: 2014-11-21T03:03:31Z
       
  • Active monitoring of potential adverse immunisation events with hospital
           admission data and linked analysis in Scotland
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Heather Murdoch , Mag McFadden , Alison Smith-Palmer , Beatrix von Wissmann , Claire Cameron
      Background Maintaining and assuring excellent immunisation safety is essential. Suspected adverse events are passively reported to the UK Medicines and Healthcare Products Regulatory Agency (MHRA). We developed a supplementary system to proactively identify recent potential adverse events resulting in admission to hospital and applied this system to rotavirus vaccine, offered to all infants across Scotland from July, 2013, at age 2 and 3 month visits. Methods All general and acute inpatient and day cases in hospitals across Scotland were included. Records for predefined potential adverse events were extracted with International Classification of Diseases 10 codes. For rotavirus vaccine, inclusion criteria were age less than 2 years, with codes of intussusception, Kawasaki disease, or anaphylaxis; and haematochezia, an intussusception marker. Primary outcome was the number of infants per month meeting inclusion criteria. Historical data were extracted, enabling presentation with Statistical Process Control methodology, with lower and upper control limits. New data points exceeding upper control limits were signals that needed further investigation. These included extracting all associated diagnostic codes, age breakdown to assess plausibility in relation to vaccination age and hospital locations, and, after formal approval, linking admissions to hospital to vaccination and laboratory reports. Findings Every month in Scotland over 9000 rotavirus vaccine doses are administered. Admissions to hospital for intussusception, Kawasaki disease, and anaphylaxis did not exceed upper control limits after vaccination. Admissions for haematochezia exceeded the upper control limit in August, 2013, 1 month after vaccine introduction. Further investigations showed that 45 infants had been admitted with the condition since vaccine implementation, 23 had been vaccinated, but only two had been admitted within 7 days of vaccination, the specific risk period. Neither of these two infants had received the vaccine outside the recommended age period, and both had other compatible reasons for haematochezia. Interpretation We have developed a timely active system for monitoring adverse events potentially associated with vaccination in Scotland. The system is limited to specified events, but it supplements MHRA reporting to provide added assurance of robust monitoring. Signals of interest can be rapidly further investigated, including near-time data linkage to the national childhood immunisation records, leading to formal epidemiological studies, if required. Funding NHS National Services Scotland.


      PubDate: 2014-11-21T03:03:31Z
       
  • Explaining ethnic inequalities in health in Scotland: a pilot study
           linking primary care to census data to account for ethnic variations in
           cardiovascular disease
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Anne Douglas , Genevieve Cezard , Markus Steiner , Colin Simpson , Colin Fischbacher , Aziz Sheikh , R Bhopal
      Background Ethnic health inequality is striking. Quantifying this inequality is important. The Scottish Health and Ethnicity Linkage Study (SHELS) linked National Health Service hospital discharges and mortality to the 2001 Scottish Census. Our analyses adjusted for age, country of birth, and socioeconomic status. However, the understanding of the role of other risk factors is crucial. The aim of this project was to explore the feasibility and value of linking risk factors from primary care to census and health data in cardiovascular disease. Methods Ten of 17 general practices in Glasgow and Edinburgh provided data relating to cardiovascular disease that were linked to census records using encrypted identifiers (for ethnic group labels, we used Census Scotland terminology). This process created a retrospective cohort study comprising 52 975 people, of whom around 8500 belonged to non-White ethnic groups. This cohort was linked to our pre-existing data on hospital admissions for cardiovascular disease. Risk ratios (RR) for first hospital admission were calculated, by sex, using Poisson regression with robust variance, adjusting for age, and then for smoking or diabetes status, with 95% CIs. The White Scottish population was the reference group (RR=100). The main outcome assessed whether ethnic variations in cardiovascular disease were attenuated on adjustment for smoking and diabetes. Ethics approval (11/MRE00/4) was obtained from Scotland A Research Ethics Committee. Findings Data completeness was similar across ethnic groups. 48 325 (91%) of 52 975 records had a valid smoking status and 2900 (5·5%) people had diabetes. Compared with White Scottish people, Pakistani people had the highest prevalence of diabetes (RR for men 274, 95% CI 238–314; RR for women 364, 305–434). Pakistani men (n=1165) and women (n=1075) were at higher risk of any hospital admission for cardiovascular disease than were White Scottish men (n=9890) and women (n=11 550) (153, 137–170 for men; 193, 158–235 for women). In Pakistani women adjustment for smoking increased the age-adjusted risk (216, 170–274), whereas adjustment for diabetes reduced the risk (161, 134–194). Interpretation The high rate of hospital admissions for cardiovascular disease among Pakistani people can be explained partly by higher rates of diabetes, but not smoking. Our dataset is a non-representative sample, so results should be treated with caution. However, we have shown potential value (for further research and for health-care planning) in linking primary care to census data to shed light on ethnic variations in cardiovascular disease. Funding Chief Scientist Office of the Scottish Government (grant numbers CZH/4/432, CZH/4/648, and CZH4/878).


      PubDate: 2014-11-21T03:03:31Z
       
  • What do people fear about cancer' A systematic review and
           meta-synthesis
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Charlotte Vrinten , Lesley M McGregor , Małgorzata Heinrich , Christian von Wagner , Jo Waller , Jane Wardle , Georgia B Black
      Background Cancer has long inspired fear but the effect of fear on early detection behaviours is not well understood. Quantitative studies suggest a complex association, with fear seeming both to facilitate and to deter early diagnosis behaviours. These inconsistencies might be partly due to the use of general measures that fail to consider whether fear of cancer has many dimensions. The aim of this study was to systematically review and synthesise the qualitative literature to explore the concept of fear of cancer. Methods We searched Medline, Embase, PsychINFO, Web of Science, and Anthrobase from Jan 1, 1992, to June 1, 2013, for qualitative studies published in English using the search terms “cancer” and “fear or worry or anxiety” and “breast or colorectal or cervical cancer screening”. Study quality was assessed but not used as a selection criterion. We took an inclusive approach to extract quotations and authors' interpretations. These excerpts were annotated and discussed among the authors to generate early themes, which were then synthesised into a higher order structure. Findings 78 studies from 23 countries were included (USA 46 [59%], UK 9 [12%], Australia 3 [4%]). Most studies involved breast cancer (41%), followed by colorectal cancer (26%), cervical cancer (23%), or more than one type of cancer (10%). Fears of cancer emanated from a core view of cancer as an unpredictable and indestructible enemy. This enemy evoked four types of fear: fears about its proximity, fears about the (lack of) strategies to keep it at a distance, fears about the personal and social implications of succumbing, and fear of dying from the disease. Interpretation This qualitative meta-synthesis drew out the multidimensionality of fear of cancer with a view of cancer as an enemy at its core, thus reprising the war-on-cancer theme that dominates the media. This enemy has various characteristics that could influence whether fight or flight is most appropriate. The view of cancer as an unpredictable and external threat can discredit messages about early detection, or impede the adoption of preventive health behaviours; future policies should focus on removing mixed messages in the public portrayal of cancer. Although only three types of cancer screening were included, evidence exists for similar fears in other populations. Funding This research was supported by a programme grant from Cancer Research UK to JWar (C1418/A14134). Cancer Research UK was not involved in the design of this study; the collection, analysis, and interpretation of the results; the write-up of the results; or in the decision to submit for publication. This abstract was not commissioned by a pharmaceutical company or other agency. CV had full access to all the data in the study and had the final responsibility for the decision to submit for publication.


      PubDate: 2014-11-21T03:03:31Z
       
  • Reflections and best practice recommendations for interdisciplinary
           working: a case study on the identification of the determinants of
           addiction from the Addiction and Lifestyles In Contemporary Europe
           Reframing Addictions Project (ALICE RAP)
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Lucy Gell , Jane McLeod , John Holmes , Emma Everson-Hock , Gerhard Buehringer , Anne Lingford-Hughes , Maria Neumann , Petra Meier
      Background Studies on the determinants of the development of substance use disorders are done across the natural and social sciences. However, research is usually conducted by individual or closely related disciplines, so evidence on how determinants from multiple disciplines interact has been slow to emerge. Within the Addiction and Lifestyles In Contemporary Europe Reframing Addictions Project (ALICE RAP) we have brought together experts from 11 disciplines in the humanities, social sciences, and medical sciences to identify the determinants of risky and harmful substance use and gambling. The aim of the present research was to explore ALICE RAP members' experiences of working with experts from diverse disciplines and to make recommendations for best practice in such projects. Methods All members of the interdisciplinary team (n=18) were invited to participate in an in-depth interview in early 2014. The aims were to explore the experience of working in an interdisciplinary manner; to identify perceived strengths and weaknesses in our approach; and to provide recommendations for future interdisciplinary collaborations. 14 experts representing ten disciplines participated. Data were analysed thematically, and recommendations were derived from suggestions made by participants and discussion among the authors on the implications of the findings. Ethics approval for this study was granted by the ScHARR Research Ethics Review Committee at the University of Sheffield in December, 2013. Findings Participants described five strengths of our approach: inclusiveness, generosity and openness of experts, flexibility, diverse forms of interaction, and the value of a dedicated facilitator or facilitators. However, the widespread view was that we had underestimated the challenge of interdisciplinary working. Specific concerns were diverse approaches to scientific evidence, differing expectations of discipline experts, ambiguity of some disciplines' roles, conflicting commitments, and a vague project endpoint. We have identified four recommendations for interdisciplinary working: to have a blueprint for the integration of disciplines, to be clear about expectations, to ensure resilient project staffing, and to talk frequently to maintain relationships and progress work. Interpretation Interdisciplinary work is challenging; however, our recommendations for interdisciplinary collaborations, identified through expert interviews, could be used to facilitate the successful planning and management of interdisciplinary work in the specialty of substance use disorders and beyond. Funding The European Union's Seventh Framework Programme for Research, technological development and demonstration under grant agreement no 266813: ALICE RAP.


      PubDate: 2014-11-21T03:03:31Z
       
  • Effect of the Great Recession on US and European health: an econometric
           analysis
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Peter A Baker
      Background The recent Great Recession, a global economic decline that started in 2007, is often presumed to have been bad for health. However, econometric studies using panel data and fixed effects suggest that, historically, recessions might be good for health. This study aimed to estimate the effect of the recessionary rise in unemployment on mortality rates, self-reported health, and health inequalities in the USA and Europe. Methods Area-level age-standardised mortality rates, percentage self-reporting poor health, and percentage unemployed were retrieved for 3087 US counties and 30 European countries from routine national databases. To compare the years before and during the recession, US data were included from 2002 to the latest available (2009). Because of the small European sample size, all available years were included to increase power (for self-reported health 2004–10, for mortality rates 1994–2010). Area-level mortality rates and the percentage self-reporting poor health were regressed on unemployment rates as panel data with area and time fixed effects. Regressions for US counties and European countries and ethnic, income, sex, and age subgroups were all run separately. Ethics approval was received from the London School of Hygiene & Tropical Medicine (application number 011/206). Findings A 1 percentage-point increase in unemployment reduced US mortality rates by 2·97 per 100 000 (95% CI 1·56–4·39, p<0·0001). There was evidence at the 10% level that this finding was replicated in Europe (reduction in mortality by 2·75 per 100 000, 6·03 to −0·52, p=0·096). There was no significant change in health inequality between black and white US citizens. An increase in unemployment by 1 percentage-point also reduced people self-reporting poor health in the USA by 0·099 percentage-points (0·201 to −0·004, p=0·061), but in Europe this was not significant. In Europe, a 1 percentage-point increase in unemployment closed the gap between the numbers of rich and poor people reporting poor health by 0·651 percentage-points (0·781 to 0·521, p<0·0001). Interpretation The original contribution of this study was the finding of a beneficial effect of the Great Recession on mortality rates, self-assessed health, and health inequalities. Health benefits could be due to fewer working hours than before the recession, safer workplaces, better health behaviours, and lower pollution and traffic. Low-income groups might gain more because of a greater reduction in dangerous employment, pollution, and traffic. Funding None.


      PubDate: 2014-11-21T03:03:31Z
       
  • Primary care competition and the effect of new providers on quality of
           care in England
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Felix Greaves , Anthony A Laverty , Utz Pape , Anenta Ratneswaren , Azeem Majeed , Christopher Millett
      Background Health system reforms in England have welcomed competition by opening broad areas of clinical practice to new providers of care. As part of these reforms new entrants, including private companies, have been allowed into the primary care market since 2004 under contracting mechanisms known as alternative provider of medical services. The characteristics and performance of general practices working under new alternative provider contracts are not well described. Methods Between 2008–09 and 2012–13, we compared performance on 17 established quality indicators that included clinical effectiveness, efficiency, access, and patient experience in all general practices in England by contract type. Data were obtained from the Quality and Outcomes Framework and General Practice Patient Survey. We used linear regression in cross-sectional and time series analyses, adjusting for practice and population characteristics and underlying trends, to compare quality in practices using alternative provider contracts to traditional practices. We created a regression model using practice fixed effects to estimate the effect on performance of practices changing to the new contract type. Findings 347 (4·1%) of 8300 general practices in England were run by alternative contract providers. These practices tended to be smaller, and serve younger, more diverse, and more deprived populations than traditional providers. Practices run by alternative providers performed worse than traditional providers on 15 of 17 indicators after adjustment for practice and population characteristics (p<0·001 for all 15), including diabetes and hypertension control, admissions for ambulatory care sensitive conditions, and overall satisfaction with care. Alternative providers had a higher percentage of patients reporting satisfaction with opening hours and higher prescribing of generic medications than did general practices not run by alternative providers. Switching to a new alternative provider contract did not result in improved performance in our fixed-effect models. Interpretation The introduction of contracts for new alternative providers to deliver primary care services in England has not led to improvements in quality and might have resulted in worse care. Strengths of our study include use of a 5-year national data sample. Limitations include risk of lack of adjustment for unmeasured confounding factors. Regulators should ensure that new entrants to clinical-provider markets are performing to adequate standards and at least as well as traditional providers. Funding There was no specific funding for this work. FG is funded by London Deanery and the Commonwealth Fund. CM is funded by the Northwest London National Institute for Health Reasearch Collaboration for Leadership in Applied Health Research & Care and the Higher Education Funding Council for England.


      PubDate: 2014-11-21T03:03:31Z
       
  • Attitudes towards lung cancer screening within socioeconomically deprived
           and heavy smoking communities: a qualitative study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Samantha L Quaife , Andy McEwen , Samuel M Janes , Jane Wardle
      Background Implementation of screening for lung cancer is being considered in the UK, but trials show a paradox in uptake—ie, individuals at highest risk of lung cancer are least likely to attend. Heavy life-long smokers are over-represented in socioeconomically deprived communities, and engaging this group in public health research is a pervasive problem. Using a proactive community-based approach to recruitment, we aimed to explore the views of smokers and ex-smokers of lower socioeconomic status towards the offer of screening. Methods Recruitment was facilitated through contact with community organisations in socioeconomically deprived areas. Settings and organisations were preferentially chosen on the basis that they did not provide a health service (ie, housing associations). Potential participants were approached or contacted directly by the researcher. Semi-structured interviews were audiorecorded, transcribed verbatim, and analysed thematically. Verbal consent was given, and ethics approval granted by University College London. Findings 21 smokers and ex-smokers (aged 47–73 years) were interviewed. Saturation was achieved with that number. Most participants (n=15) were from the UK's most socioeconomically deprived quintile and had left school aged 15 years or younger. Most were supportive of screening, citing the benefits of reassurance, better outcomes with early detection, and getting one's affairs in order. Discussions gave insight into potential barriers to screening, including fear that it was too late (age and smoking history were cited), control over lung cancer (other causes, fatalism, lung cancer as incurable), and concern about treatment (living without lungs, quality of life). Conversations sometimes led participants to explain their smoking history, with some identifying the need to normalise the offer of screening so as to avoid recipients feeling singled out. Smoking cessation advice after screening was regarded as appropriate if delivered sensitively. Interpretation The recruitment of smokers of lower socioeconomic status indicates that this hard-to-reach target group can be engaged in public health research by use of existing community networks, although these methods are labour-intensive and difficult to replicate. The generalisability of our findings is restricted to English-speaking urban communities. Our findings indicate that attitudes towards lung cancer screening are complex and not wholly positive, and must be considered carefully in designing screening invitations. Funding SLQ is supported by a Medical Research Council studentship. JW is supported by Cancer Research UK.


      PubDate: 2014-11-21T03:03:31Z
       
  • Interpretation and use of official drinking guidelines by adults in
           England and Scotland: a qualitative study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Melanie Lovatt , Douglas Eadie , Petra Meier , Jessica Li , Linda Bauld , Gerard Hastings , John Holmes
      Background The UK Government is reviewing its low risk drinking guidelines for adults. However, there is a lack of evidence on the public's understanding and use of official guidance on alcohol consumption. We aimed to explore qualitatively adult drinkers' awareness, interpretation, and use of current drinking guidelines; and their beliefs and practices around self-regulation of their alcohol consumption. Methods 12 focus groups were conducted in England and Scotland during early 2014 with drinkers aged from 19 to 64 years (n=66). Independent market research consultants identified, recruited, and took informed consent from participants. Participants were recruited door-to-door from eight locations in England and Scotland. Participants were each given £25 for taking part. Participants were purposively sampled and grouped by age, sex, and socioeconomic background (professional and technical, unskilled and manual). Participants were asked about their awareness of the current drinking guidelines, their views on the purpose of guidelines, how they interpret and use the guidelines, and other strategies they have for regulating their alcohol consumption. The focus groups were audiorecorded, transcribed verbatim, and coded with NVivo (version 10) software. The data were analysed thematically. Ethics approval was granted by the University of Sheffield and the University of Stirling. Findings Participants disregarded the drinking guidelines for two main reasons. First, the guidelines were regarded as irrelevant to participants' existing drinking practices. Reasons given included the dissonance between the guidelines, which are aimed towards regular drinking, and the participants' tendency to binge drink at weekends; the disconnect between amounts given in the guidelines and participants' typical consumption levels; and problems of measuring and monitoring units. Second, participants perceived a lack of information on the scientific evidence behind the guidelines and the consequences of exceeding them. Interpretation Governments need to ensure that guidance they provide on alcohol consumption is useful and meaningful to drinkers, and understand how people use it to inform their behaviour. Our findings suggest a disconnect between the drinking guidelines and commonplace drinking practices, and a credibility gap that is a barrier to the guidelines' effective use. People responsible for developing and designing drinking guidelines should seek to better reflect drinking practices and evidence concerns when communicating guidance. Funding Medical Research Council National Prevention Research Initiative (grant number MR/J000523/1).


      PubDate: 2014-11-21T03:03:31Z
       
  • National supervised toothbrushing programme in Scotland, 1986–2009:
           trends over time, reduction in inequality, and cost analysis
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Yulia Anopa , Alexander Douglas McMahon , David Ian Conway , Graham Edmund Ball , Emma McIntosh , Lorna Margaret Davidson Macpherson
      Background Dental decay is one of the most common diseases of childhood. In the 1990s Scottish children had among the worst rates of dental decay in the UK and Europe. We aimed to assess the association between the roll-out of nursery toothbrushing within the national Childsmile programme and a reduction in dental decay in 5-year-old children and to assess cost savings. Methods The intervention was supervised toothbrushing in nurseries measured as the percentage of nurseries participating in all Scottish health boards. The endpoint was mean d3 mft (number of teeth decayed into the dentine, missing, or filled) in 99 071 children aged 5 years, covering 7–25% of the population, who participated in multiple cross-sectional dental epidemiology surveys in 1987–2009 (conducted every 2 years in every health board). Estimated costs of the nursery toothbrushing programme in 2011 were requested from all health boards. Unit costs of filled, extracted, and decayed teeth were calculated. The total costs associated with actual and anticipated dental treatments were estimated for 1999–2009. These costs were based on the unit costs and on data from the dental epidemiology surveys and then extrapolated to the population level. Savings were calculated for the subsequent years in comparison with the reference 2001 dental treatment costs. Findings Mean d3mft in years −2 to 0 (relative to that in toothbrushing start-up year 0) was 3·06, reducing to 2·07 in years 10 to 12 (mean difference −0·99, 95% CI −1·08 to −0·90; p<0·0001). This improvement was greater for children in the most deprived areas (−1·71, −1·93 to −1·49; p<0·0001) than for children in the most affluent areas (−0·43, −0·60 to −0·25; p<0·0001). The uptake of toothbrushing correlated with the decline in d3mft (correlation −0·64, p=0·011). The estimated cost of the nursery toothbrushing programme in Scotland was £1 762 621 per year. The estimated savings ranged from £1 217 255 in 2003 (13·9% of costs in 2001) to £4 731 097 in 2009 (54·0%). Interpretation An improvement and reduction in inequalities in the dental health of 5-year-old children was detected and was associated with the uptake of nursery toothbrushing. The costs associated with the actual and anticipated dental treatments for 5-year-old children decreased over time. In the eighth year of the toothbrushing programme the savings were more than two and a half times the costs of the programme implementation. Funding Childsmile is funded by the Scottish Government. Dental epidemiology surveys data collections were funded by the National Health Service.


      PubDate: 2014-11-21T03:03:31Z
       
  • Measurement of the incidence of poisonings, fractures, and burns in
           children and young people with linked primary and secondary care data: a
           population-based cohort study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Ruth Baker , Elizabeth Orton , Laila J Tata , Denise Kendrick
      Background Existing injury studies are often limited by use of single data sources to identify injury events, leading to underestimation of injury incidence. With the recent availability of linked primary and secondary care data, we aimed to develop methods to comprehensively identify injury types and mechanisms, and to define incident injury events across linked data sources. Methods We used linked primary and secondary care data from the Clinical Practice Research Datalink (CPRD), and Hospital Episode Statistics (HES) in an open cohort study. Participants (n=2 269 626) were children and young people aged 0–24 years between 1997 and 2012, who were registered at general practices in England contributing to the CPRD database and who also had linked HES data. Time-based algorithms were developed to define incident poisoning, fracture, and burn events. Proportions of injuries with a recorded mechanism were assessed in CPRD and HES. Incidence rates were calculated with data from CPRD, HES, and linked CPRD-HES for each injury type. Ethics approval was obtained from the Independent Scientific Advisory Committee for the Medicines and Healthcare Products Regulatory Agency in December, 2013. Findings Using linked CPRD-HES data, we identified 45 161 poisoning, 199 158 fracture, and 38 195 burn events among our cohort, of which 9930 (22%), 18 445 (9%), and 1763 (5%), respectively, were only included in HES, and 23 462 (52%), 151 237 (76%), and 34 805 (91%), respectively, were only included in CPRD. In linked data, incidence rates of poisonings, fractures, and burns were 42·2 per 10 000 person-years (95% CI 41·8–42·6), 186·0 (185·2–186·9), and 35·7 (35·3–36·0), respectively. Rates in CPRD were lower than those in linked data: 32·9 (32·6–33·3), 168·8 (168·0–169·6), and 34·0 (33·7–34·4), respectively. Injury mechanisms were identified for 3856 fractures (2%) and 1893 burns (5%) in CPRD, compared with 39 339 (82%) and 2690 (79%), respectively, in HES. Interpretation Our algorithms to identify injury events and their timing across primary and secondary care data show that use of linked data to increase injury ascertainment is crucial. Although non-medically attended injuries will not be captured in this study, our estimates provide useful information about the burden of medically attended injuries, which is important for health service planning. Our methods also provide essential information about the recording of injury mechanisms according to data source—an issue of importance for injury prevention practice and research. Funding RB is part funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR).


      PubDate: 2014-11-21T03:03:31Z
       
  • Spatial variation in heart failure and air pollution in Warwickshire, UK:
           an investigation of small scale variation at the ward level
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Oscar Bennett , Ngianga-Bakwin Kandala , Chen Ji , John Linnane , Aileen Clarke
      Background Air pollution has been linked to the development and exacerbation of various health problems, including cardiovascular diseases such as heart failure. This project sought to spatially map the morbidity and mortality caused by heart failure within the county of Warwickshire, UK, to characterise and quantify any influence of air pollution on these risks. Methods Data on air pollution, hospital admission for heart failure, and mortality within 105 Warwickshire county wards were collected from 2005 to 2013. Air pollution data included mono-nitrogen oxide (NOx), sulphur dioxide (SO2), particulate matter (PM), and benzene, which could then be united into a combined index. We used Bayesian geo-additive mixed models to map the spatial distribution of air pollution and heart failure data at the county level, accounting for county risk factors. Findings During 2005–13 in Warwickshire, heart failure led to 5045 hospital admissions and 479 deaths. In multivariate analyses, presence of NOx, benzene, and index of multiple deprivation (IMD) score were consistently associated with risk of heart failure morbidity (posterior mean PM 3·35, 95% credible region 1·89–4·99 vs 31·9, 8·36–55·85 vs 0·02, 0·01–0·03). PM was negatively associated with the risk of heart failure morbidity (−12·93, −20·41 to −6·54) but no association with SO2 was seen. Risk of heart failure mortality was higher in wards with a high NOx (4·30, 1·68–7·37) and in wards with more inhabitants older than 50 years (1·60, 0·47–2·92). PM was negatively associated with heart failure mortality (−14·69, −23·46 to −6·50). SO2, benzene, and IMD score were not associated with heart failure mortality. There was a striking variation in heart failure morbidity and mortality risk across wards, the highest risk being in the regions around Nuneaton and Bedworth (appendix). Interpretation This study showed distinct spatial patterns in heart failure morbidity and mortality in Warwickshire, suggesting a potential role of air pollution beyond individual-level risk factors. Environmental factors should therefore be taken into account when considering the wider determinants of public health and the effect that changes in air pollution might have on the health of a population. Funding This paper presents independent research supported by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands.


      PubDate: 2014-11-21T03:03:31Z
       
  • Use of the child health utility and strengths and difficulties outcome
           measures in economic evaluations of school-based interventions: data from
           a cluster-randomised controlled trial in Northern Ireland
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Nicole Boyer , Sarah Miller , Paul Connolly , Emma McIntosh
      Background There is growing evidence linking early social and emotional wellbeing to later academic performance and various health outcomes including mental health. An economic evaluation was designed alongside the Roots of Empathy cluster-randomised trial evaluation, which is a school-based intervention for improving pupils' social and emotional wellbeing. Exploration of the relevance of the Strengths and Difficulties Questionnaire (SDQ) and Child Health Utility 9D (CHU9D) in school-based health economic evaluations is warranted. The SDQ is a behavioural screening questionnaire for 4–17-year-old children, consisting of a total difficulties score, and also prosocial behaviour, which aims to identify positive aspects of behaviour. The CHU9D is a generic preference-based health-related quality of life instrument for 7–17-year-old children. Methods Non-randomised SDQ (total difficulties and prosocial behaviour scores) and CHU9D utility values were reported with standard descriptive statistics at baseline (n=1179), after intervention completion (n=1181), and 12-month follow-up (n=1277) from intervention completion. Agreement between the measures was based on Spearman's rank correlation coefficient, graphical techniques, and simple calculations. Regression analysis was carried out to assess the effect and variation in SDQ and CHU9D utility values in relation to age, sex, and deprivation. Findings Mean CHU9D utility values were 0·84 (SD 0·11) at baseline, 0·85 (0·11) after intervention completion, and 0·85 (0·10) at 12-month follow-up. Mean SDQ total difficulties scores were 12·11 (3·27), 11·78 (3·14), and 11·95 (3·07), respectively. Mean SDQ prosocial behaviour scores were 8·12 (2·18), 8·42 (2·00), and 8·62 (1·93), respectively. A correlation between total difficulties and utilities at baseline and 12-month follow-up was evident (r=–0·10, p=0·004 and −0·08, p=0·018). No correlation was found after intervention completion or between prosocial behaviour and utilities. Multivariate regression analysis showed that child health utilities were significantly associated with total difficulties score at baseline (β=–0·09, 95% CI −0·03 to −0·16; p=0·007) and after intervention completion (−0·08, −0·01 to −0·15; p=0·016) after adjustment for deprivation. No significant association between utilities and total difficulties was found at 12-month follow-up. However, child health utilities were significantly associated with prosocial behaviour at 12-month follow-up (0·05, 0·01–0·08; p=0·010) after adjustment for age. No significant association between utilities and prosocial behaviour was found at any other timepoints. Interpretation The SDQ and CHU9D are able to measure outcomes in children aged 8–10 years within an educational setting and there is initial evidence that they are related in their measurement properties. To our knowledge, the SDQ and CHU9D have not yet been used to predict longer-term outcomes within an economic evaluation context. This is an important avenue for further research because issues remain as to whether these childhood measures could be extrapolated into adulthood. A decision analytic model for long-term analysis is now being developed. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme.


      PubDate: 2014-11-21T03:03:31Z
       
  • Age-friendly towns and cities: a mixed methods approach to developing an
           evaluation instrument for public health interventions
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Nigel Bruce , Cherie McCracken , Stefanie Buckner , Mukesh Dherani , Rory McGill , Sara Ronzi , Daniel Pope , Louise Lafortune , Karen Lock , Martin White
      Background In the context of population ageing and urbanisation, a growing number of cities are adopting the WHO's Age-Friendly Cities (AFC) framework, which incorporates eight interlinking domains. This study set out to design an evidence-based instrument to assess interventions intended to make urban settings more age-friendly. Methods Fieldwork is taking place in Liverpool, UK. A needs assessment used census, Hospital Episode Statistics, and Ambulance Service data and highlighted falls as a local health priority for older people (65 years or older). Health, environmental, and social science databases (including PubMed, Scopus, and Web of Science) were systematically searched to identify systematic reviews from Jan 1, 2000, to July 31, 2014, in English that described effective falls-related interventions. Examples of keywords for age were old* people* OR old person* OR age* 65* OR elder*. Examples for review were systematic review* OR narrative review* OR integrated review* OR review*. Examples for falls were fall* OR outdoor safety OR trip hazard*. Interviews with key informants (n=12) from different sectors as well as interviews (n=20) and focus groups (n=2, 10 participants each) with older people on falls-related provision are proceeding. The research is informing the development of an evidence-based evaluation instrument that can be applied to settings and interventions more widely. The instrument will be pilot-tested for usability, with in-depth validation planned for a further project phase. Findings Analysis of available data has shown a high incidence of and case fatality from falls, and it has revealed common causes and locations of falls in Liverpool. The effective falls-related interventions identified were mapped onto the WHO domains to highlight important areas of provision. Strongly represented were interventions that relate well to the domains of Community Support and Health Services and Housing (eg, home modifications). The domains of Outdoor Spaces and Buildings and Transportation were identified as important areas for provision, although the evidence base was more limited. Analysis of qualitative data is exploring whether this pattern is reflected in Liverpool's falls-related provision. The evidence mapping, together with the primary data, allows presentation of a picture of strengths and gaps in falls-related provision in Liverpool in relation to the AFC domains. Interpretation Data collection has highlighted key dimensions to be incorporated in the evaluation instrument. These dimensions include consideration of the extent to which AFC initiatives are informed by a needs assessment and robust research evidence, political will, availability of resources, attention to target group perspectives, and plans for evaluation. Funding This project is funded by the National Institute for Health Research School for Public Health Research (SPHR) as part of SPHR's Ageing Well programme of research.


      PubDate: 2014-11-21T03:03:31Z
       
  • Evaluation of diagnosed incidence rate as a measure of performance: an
           ecological study of England's national chlamydia screening programme
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Lakshmi Chandrasekaran , Bethan Davies , Jeffrey W Eaton , Helen Ward
      Background England's National Chlamydia Screening Programme (NCSP) aims to control infection and reduce sequelae. Public Health England developed a novel monitoring indicator included in the Public Health Outcomes Framework, the diagnosed incidence rate (DIR), with a target of 2300 cases of chlamydia per 100 000 resident 15–24-year-old young people per year. We assessed the utility of DIR as a measure of performance at local authority level. Methods We used the NCSP 2012 dataset to derive coverage, positivity, population size, and DIR and linked the dataset to indices of multiple deprivation (IMD) 2010 scores. We used multivariate logistic regression to analyse the association between the DIR (local authorities categorised as achieved or did not achieve the target) and coverage, positivity, population size, IMD score, and proportion of tests done in a genitourinary medicine setting. Findings The dataset included 3 403 922 female residents and 3 516 609 male residents from 326 local authorities, two of which were excluded (one with missing values and one suppressed because of small numbers). The recommended DIR of 2300 per 100 000 was achieved by 72 (22%) of 324 local authorities, with those in the most deprived quintile being more likely to reach the target than those in the least deprived quintile (adjusted odds ratio [AOR] for women 25·83, 95% CI 8·70–76·68; men 6·83, 1·34–34·72). The proportion of tests done in a genitourinary medicine setting was negatively associated with attaining the recommended DIR (AOR 0·93, 95% CI 0·91–0·96). No clear associations with population size were seen. Interpretation Greater socioeconomic deprivation strongly influenced whether local authorities attained the recommended DIR. This finding could reflect increased disease burden rather than more appropriate targeting of testing. Consequently, use of the DIR to compare performance of local authorities is difficult. Local-authority-specific DIR targets that reflect local disease burden might be more effective than a single national target. Additionally, the results indicate that an increased proportion of tests done in a genitourinary medicine setting was associated with a reduced likelihood of reaching the DIR target, which suggests the need for more testing outside of this setting, particularly in the least deprived areas. Critical evaluation of local authority performance should be used to inform subsequent versions of the Public Health Outcomes Framework. Funding BD received a Medical Research Council Population Health Scientist Fellowship. JWE received funding from the Bill & Melinda Gates Foundation through a grant to the HIV Modelling Consortium.


      PubDate: 2014-11-21T03:03:31Z
       
  • Disinvestment and reinvestment in respiratory care: use of programme
           budgeting and marginal analysis in north Wales, UK
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Joanna Mary Charles , Graham Brown , Kathrin Thomas , Ffion Johnstone , Andrew Jones , Rhiannon Tudor Edwards
      Background Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Since health boards face increasing pressure to deliver services that are value for money, a programme budgeting marginal analysis (PBMA) of respiratory care was commissioned. Methods A research group with health economics, clinical, National Health Service (NHS) finance, and pharmacy prescribing expertise was established to gather evidence on the current respiratory care pathway in north Wales and to recommend where expenditure within the service should be focussed using PBMA. A PBMA panel was established consisting of managers and directors of medicines' management, therapies, finance, planning, and health-care professionals. The review identified a budget of £86·9 million spent on respiratory care in 2012–13 for a population of 700 000. With an agreed list of criteria developed by the research team and the panel, electronic voting was used to establish criteria for decision making and vote on candidates to disinvest and reinvest in. The panel was also asked to make a set of recommendations about the allocation of funding within the respiratory service. Evidence was provided in a booklet of the potential for cost savings (from NHS finance staff) and health benefits (from a rapid review of the evidence) of the proposed recommendations to equip the panel with the notion of opportunity cost when making their investment and disinvestment decisions. Findings 13 candidates were discussed; they were individual proposals for resource reallocation, ranging from specific interventions to cross agency partnership. After extensive discussion facilitated by a chairperson, four candidates received recommendations to disinvest, seven to invest, and two to maintain current activity. The panel were also able to rank the candidates in order of highest priority for the health board to lowest priority. Interpretation This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and reinvestment decisions. This exercise, though in its early stages, could offer further support for changes in respiratory care implementation in north Wales, if recommendations were to be implemented. PBMA also has wider implications across health agencies in the UK for resource allocation decisions, such as diabetes care. Funding None.


      PubDate: 2014-11-21T03:03:31Z
       
  • Communication of local cancer statistics to influence policy, and local
           engagement to improve cancer outcomes
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Carina Crawford , Becky White , Rosie Hinchliffe , Nick Ormiston-Smith
      Background The accessibility of open data means that ever more information is available, and it is important that the public and policy makers are able to make sense of it. Cancer Research UK developed an interactive website that places cancer data in a local context. The aim is to support decision makers and health professionals by highlighting areas for improvement at a local level. In addition to the interactive website, more in-depth analysis of general practice statistics provides general practitioners with better contextualisation of their local population. Methods The interactive website compiles publicly available local data for epidemiology, risk factors, and early diagnosis from a range of sources. Locations can be compared with the national average and with other areas on the basis of statistically significant differences. Local area statistics are also matched to parliamentary constituencies to engage policy makers. Data are converted to intelligence with recommended actions and presented by means of infographics. In addition, to support general practitioners, regression analysis of screening coverage data for general practices linked to practice demographic data provided a model to predict the expected screening coverage. Findings Local statistics show variation in risk factor prevalence and hence cancer burden and outcomes. These data inform evidence-based discussions with politicians as demonstrated by Members of Parliament referencing our analyses during parliamentary debates and in constituency press releases. Our user surveys indicate that 70% of health professionals using the interative website found the content relevant. Modelling of screening data shows that variation in screening coverage across general practices is explained to varying degrees by several patient population characteristics. The difference between the expected and actual coverage identified whether each practice achieved a higher or lower screening coverage than predicted. Users found the results helpful as demonstrated by requests for additional analysis and further partnership working. Interpretation This web resource enables local variations in data to be explored, highlighting the challenges and opportunities for improving outcomes locally, helping to raise cancer awareness, and identifying where action needs to be taken to reduce inequalities. Modelling results communicated with general practitioners face-to-face provides an improved indication of practice screening performance, and supports them in improving early diagnosis. Funding None.


      PubDate: 2014-11-21T03:03:31Z
       
  • Behaviour change in 160 characters: a novel brief alcohol intervention for
           disadvantaged men
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Iain K Crombie , Donald W Falconer , Linda Irvine , Brian Williams , Ian W Ricketts , Gerry Humphris , John Norrie , Peter Rice , Peter W Slane
      Background Men from disadvantaged areas experience substantial alcohol-related harm. However such men can be missed by the conventional method of delivering brief alcohol interventions through primary care. This feasibility study designed and evaluated the potential of a brief alcohol intervention delivered by text message. The intervention aims to reduce the frequency of binge drinking. Methods Disadvantaged men aged 25–44 years who had two or more episodes of binge drinking (≥8 units of alcohol in a single session) in the preceding month were recruited and randomised to receive either text messages designed to encourage moderated drinking (intervention group) or general health messages (control group). We report here on the feasibility of study methods. Two recruitment strategies were used: general practice registers and community outreach. The intervention drew on literature on alcohol brief interventions, text message studies, communication theory, and behaviour change theories and techniques. Tailored text messages were developed through focus groups with disadvantaged men. Findings Both recruitment strategies proved successful, with 67 men recruited (target=60). At baseline many men had regular heavy drinking episodes interspersed with several days of sobriety. About a quarter of men had frequent episodes of failing to remember the night before. Men recruited through community outreach drank more than double that of men recruited through general practices (mean 137·1 units per month [SD 134·9] vs 61·7 [50·0], p=0·006). More men recruited through community outreach than through practices had greater than 5 binge drinking days per month (17/30 [57%] vs 6/37 [17%], p=0·02). Retention at follow-up was 96% (64/67). Extensive process evaluation showed that 1053 (95%) of 1108 text messages were successfully delivered to participants' phones. In addition, a high level of engagement with text messages was noted, with 30 (88%) of 34 participants in the intervention group responding to messages that asked questions. Content analysis of responses showed engagement with key components of the behaviour change strategy. Post-study evaluation showed high levels of satisfaction with the intervention. Interpretation Disadvantaged men were successfully recruited and retained in an alcohol intervention study. A theoretically and empirically based intervention was successfully delivered by text message. Furthermore, the messages were well received and elicited the types of response intended. This feasibility study suggests that the intervention offers a low-cost method of reaching large numbers of hazardous drinkers. Funding This project was funded by the National Institute for Health Research Public Health Research programme (project number 09/3001/09).


      PubDate: 2014-11-21T03:03:31Z
       
  • Visual health inequalities: findings from UK Biobank
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Phillippa M Cumberland , Jugnoo S Rahi
      Background Little is known about inequalities in eye health. Between 2009 and 2010, 117 908 UK Biobank participants (aged 40–69 years) undertook an ophthalmic assessment, which included distance visual acuity. UK Biobank was not designed to be a fully representative population sample so prevalence estimation is precluded. However, the size and diversity of the sample provide a unique opportunity for investigation of socioeconomic influences on visual health in UK adults. Methods Habitual (usual optical correction) distance acuity was measured with a standardised computer-based system. 112 314 participants were reliably assigned, on the basis of acuity in the better eye, into one of six categories spanning the spectrum of vision from bilateral normal vision (log of minimum angle of resolution [logMAR] 0·2 or better) to low-vision–blind (≤0·5, WHO taxonomy). Socioeconomic information included educational qualifications and Townsend Index. Multinomial and ordinal regression analyses were undertaken. Findings The frequency of normal bilateral vision decreased with age (age 40–49 years, 86% [21 934/25 645]; 50–59 years, 77% [27 482/35 786]; and 60–70 years, 72% [36 461/50 883]). Overall, risk of visual impairment across severity categories was associated with an increasing gradient of key demographic and socioeconomic variables, indicating deprivation. These patterns of visual health inequalities were not explained by risk of underlying eye disease. For example, compared with normal vision, socially significant visual impairment (SSVI), a mid-range category of visual impairment, was associated with increasing age (risk ratio 1·05, 95% CI 1·046–1·06), being female (1·09, 1·01–1·16), no educational qualifications (1·7, 1·4–1·9), a higher deprivation score (1·08, 1·07–1·09), and being part of any minority ethnic group (eg, Asian 2·5, 2·1–2·9). Participants unable to work or unemployed were at least 30% more likely to be in the SSVI category than were those with normal vision and, if employed, at least 9% more likely to have a lower status job. Interpretation There are consistent patterns of associations between visual impairment across the full spectrum including, importantly, people with mild impairment, and known health determinants as well as key social outcomes. To our knowledge, our study provides evidence for the first time that policies tackling health inequalities as well as initiatives to address inequalities in ophthalmological clinical settings have the potential to improve visual health outcomes. Funding This work was funded by the National Eye Research Centre. PMC is funded by the Ulverscroft Foundation and JSR receives part funding from the National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and University College London Institute of Ophthalmology. The study was undertaken at University College London Institute of Child Health, which receives a proportion of its funding from the Department of Health's NIHR Biomedical Research Centres funding scheme.


      PubDate: 2014-11-21T03:03:31Z
       
  • Do regional labour market conditions affect transitions into employment
           from health-related inactivity' Multilevel analysis of longitudinal UK
           Labour Force Survey data
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Esther Curnock , Alastair H Leyland , Frank Popham
      Background Long-term worklessness (unemployment or economic inactivity) is associated with adverse health outcomes and inequalities. Recent UK welfare reforms, alongside other return-to-work policies, have aimed to increase employment rates for people who have been out of the labour market because of sickness and disability. However, sickness benefit claimant counts vary substantially by geographical area and are highest in the post-industrial regions with the weakest economies. The aim of this study was to investigate whether local labour market conditions affect transitions from health-related inactivity into employment and compare them with transitions from unemployment to work. Methods Longitudinal Labour Force Survey datasets were used to follow working age individuals resident in Great Britain over five consecutive quarters. Datasets from 1999–2013 were pooled (quarter 1 health-related inactivity group n=29 130, unemployed group n=14 873). Multilevel logistic regression models (region at level 3, year-within-region at level 2) were constructed with employment at quarter 5 (Q5) as the main outcome measure. Annual male regional employment rates were used as a proxy for local labour market conditions. Findings Transitions into employment for the health-related inactivity group were rare (1057/29 130 [3·6%] at Q5) compared with the unemployed group (6255/14 873 [42·1%]). Regional variance was significant at baseline (p=0·03), and adding local employment rates as a fixed effect eliminated all observed area-level variability. A 1% increase in local employment rates was associated with an unadjusted odds ratio (OR) of transition to employment for the health-related inactivity group of 1·08 (95% CI 1·05–1·10) and for the unemployed group 1·08 (1·06–1·10). Adjustment for sex, age, education, and long-term health status had little effect (health-related inactivity group adjusted OR 1·07, 1·05–1·10). Interpretation Local labour market conditions fully account for regional differences in transition rates from health-related inactivity into employment. Higher regional employment rates are associated with increased rates of return to employment, and this association is similar to that for unemployed groups; however, overall rates of transition were low compared with unemployed groups. One limitation of our study is loss to follow-up. Local labour market improvement could potentially increase return-to-work rates for the sick and disabled. Public health advocacy and collaborative action with policy makers in local and national government is needed to address this issue. Funding EC receives funding from the Chief Scientist Office of the Scottish Government Health Directorates (SPHSU1) as part of the Evaluating the Health Effects of Social Interventions programme at the Medical Research Council/Chief Scientist Office (MRC/CSO) Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. AHL receives core funding from the UK Medical Research Council (MC_UU_12017/5) and the Chief Scientist Office of the Scottish Government Health Directorates (SPHSU2) as part of the Measuring Health programme at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. FP receives core funding from the UK Medical Research Council (MC_UU_12017/7) as part of the Social Patterning of Health over the Lifecourse Programme at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.


      PubDate: 2014-11-21T03:03:31Z
       
  • Seasonal influenza in medical students: an outbreak simulation model based
           on a social network approach
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Rhiannon Edge , Joseph Heath , Barry Rowlingson , Thomas Keegan , Rachel Isba
      Background There is increasing interest in the effects of social networks on disease dynamics. We simulated the spread of influenza through a population of medical students where transmission was related to the social network structure and vaccination status of individuals. Methods All students at Lancaster Medical School, Lancaster, UK (n=253) were asked to rate the strength of their relationship with all other students from the medical school. Students also self-reported their influenza vaccination status. An individual-based outbreak model was developed using R statistical software. Using these data, combined with appropriate transmission parameters, we simulated an influenza outbreak and assessed the effects of preferentially vaccinating according to the social network analysis data. We ran the simulation 1500 times. Each simulation selected a random student to introduce the virus into the population. For each vaccination strategy, the likelihood of each individual being infected was calculated as a percentage of the number of times they were infected in the 1500 possible outbreaks. Findings 215 students (85%) responded. Non-responders were assumed to have reciprocal relationships with responders; therefore it was possible to construct the entire medical student network. We found that the outcomes of vaccination strategies based on between-ness (the extent to which an individual lies between others in the network) and degree (the number of connections an individual has), which are both measures of connectedness, quickly converged. As more individuals were vaccinated, the likelihood of individuals contracting the infection tended to be similar, irrespective of vaccination based on between-ness or degree. After vaccination of an additional 8% of the population (20 students) the outcome of the experimental influenza outbreak was similar for both strategies. Interpretation Our results add to a small pool of evidence supporting targeting vaccination of individuals according to between-ness in an attempt to reduce the spread of influenza. However, in small, densely connected populations, vaccination according to degree might be preferential because of the rapid convergence and the relative ease of locating individuals with a high degree versus those with high between-ness. This study suggests that vaccination strategies that target highly connected individuals within a network might limit spread of infectious disease. Future work could include evaluating current vaccination approaches using social network analysis. Funding University Hospitals of Morecambe Bay NHS Foundation Trust funded data collection.


      PubDate: 2014-11-21T03:03:31Z
       
  • Use of retail data in the assessment of natural experiments: the case of
           Reducing the Strength, an intervention to reduce alcohol availability
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Matt Egan , Triantafyllos Pliakas , Daniel Grace , Elizabeth McGill , Amanda Jones , Justin Wong , Simon Aalders , Karen Lock
      Background Retailers routinely collect data about people's purchasing behaviours and access to consumer products associated with health and wellbeing. Here we discuss how retail data can be used in public health research and consider potential strengths and limitations to such research. To illustrate the discussion we refer to an evaluation of an intervention called Reducing the Strength, whereby off-licence shops and supermarkets voluntarily stopped selling inexpensive superstrength (≥6·5% alcohol by volume) beers and ciders. Methods Monthly data from a large retail chain (East of England Co-operative Society) were obtained for three UK counties (141 stores). In one county the intervention started 12 months earlier than the others, allowing for a pre–post study design with a delayed implementation comparator. Difference-in-differences analysis of unit alcohol sales controlled for socioenvironmental confounders and shop-level characteristics including shop size, parking facilities, cash machines, opening hours, and other factors. Findings The retail data detailed shop-level characteristics and sales data such as prices, quantities, product brands, alcohol content, sales, and factors affecting sales. The wide geographical coverage, shop-level data, including data for potential confounding factors, and frequent timepoints made the retail data well-suited for a quasi-experimental evaluation capitalising on temporal and spatial variations in intervention exposure. Limitations of this study include a lack of longitudinal data for individual customers, and shops that are not covered by the data. Qualitative interviews with shop workers and customers, and triangulation using alternative data sources can help to address limitations. Alternative sources of retail data such as private sector consultants who specialise in collecting shop-level and sales data for a range of companies might also address some limitations; however, there are potential barriers of expense, accessibility, and coverage associated with the use of such consultants. Interpretation Increasingly, researchers recognise the potential of retail data for evaluating interventions affecting social determinants of health and inequalities, such as local access to alcohol. However, shop-level data have frequently proved difficult for researchers to obtain. By obtaining such data we have been able to assess, using a quasi-experimental design, the effects of removing strong, cheap beers and ciders from shops. We have also been able to explore in more detail how to optimise the strengths and address some limitations of the data in ways that could potentially assist others planning to use this important data source in their research. Funding The study is funded as part of the School of Public Health Research by NHS National Institute of Health Research. AJ, SA, and JW contributed as employees of Public Health Suffolk, Suffolk County Council.


      PubDate: 2014-11-21T03:03:31Z
       
  • High risk of hepatitis B virus infection and unmet case-finding need among
           migrants in Bristol, UK: a cross-sectional study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Iro Evlampidou , Matthew Hickman , Charles Irish , Alexandra Cochrane
      Background In 2012, the National Institute for Health and Care Excellence (NICE) recommended (public health guidance 43) hepatitis B virus (HBV) testing of people born in countries with a prevalence of more than 2%. Country of birth is not captured in routine HBV surveillance so prevalence of HBV infection in immigrants to the UK by country of birth is unclear. Also, the proportion of migrants tested for HBV is unknown. This cross-sectional study aimed to estimate the proportion of migrants tested for HBV, and the prevalence of HBV infection in HBV-tested migrants by country of birth. Methods All people living in Bristol and registered with a general practitioner (GP) in 2006–13 were included. Country of birth was obtained from the national patient demographic system. We defined a person as not HBV tested if no test result was recorded in the Public Health England Laboratory Bristol records (2006–13) and as HBV infected if HBsAg was positive or if HBV DNA was detected. The sensitivity of this method in detecting HBV-infected people was checked by review of primary care records. Findings Of 687 483 patients registered with a GP in 2006–13, 82 561 (12%) were born in a country with an HBV prevalence of more than 2%, and for 194 025 patients (28%) country of birth was unknown. Of the 82 561 eligible patients, 72 934 (88%) were not HBV tested. Of those who were HBV tested, first tests were requested antenatally in 40% (3875/9627) (1·0%, 39/3857 HBV infected) and by primary care in 42% (4078/9627) (6·1%, 249/4078 HBV infected). The period prevalence of HBV infection by UN subregion of birth was: Eastern Asia 14·8% (63/427) of all tested patients versus 3·1% (5/160) of those tested antenatally, Western Africa 11·6% (68/588) versus 4·2% (8/191), South-Eastern Asia 6·8% (35/515) versus 2·0% (4/205), and Eastern Africa 5·6% (133/2363) versus 1·4% (11/809). In all the remaining subregions the period prevalence in those tested antenatally was less than 1%. 179 054 (92%) of individuals with unknown country of birth were not HBV tested, and among those tested, 0·5% (80/14 971) were HBV infected. Interpretation In a large UK city, most GP-registered migrants, for whom a HBV test was recommended by NICE, had not been tested. The proportion not HBV tested in all migrants in Bristol might be higher because testing could be less likely in those not registered with a GP. Those migrants born in Eastern and South-Eastern Asia and West Africa were at greatest risk of infection. Funding This study was supported with an educational grant via the Gilead UK and Ireland Fellowship Programme. The funder had no role in design of the study, data collection, analysis, interpretation, abstract preparation, or decision to submit.


      PubDate: 2014-11-21T03:03:31Z
       
  • Not that different or just not measurable' The contribution of health
           care to changes in population health outcomes in the UK before and after
           devolution
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Josephine Exley , Marina Karanikolos , Nicholas Mays , Ellen Nolte
      Background The extent to which health care makes a difference to population health outcomes continues to be debated among researchers and practitioners alike. The National Health Service (NHS) in the UK provides an important natural experiment to study this association. In this study we aimed to quantify it using mortality from causes considered amenable to health care (amenable mortality), assessing trends before and after political devolution in 2000 in the four countries of the UK. Methods We assessed pre-devolution (1990–2000) and post-devolution (2000–12) trends in age-standardised death rates from amenable mortality among those aged 0–64 years, 65–74, and 0–74. We estimated absolute change over 1990–2012 by fitting a linear regression and relative change as the average annual percentage change. We fitted a Poisson regression model to estimate relative risk (RR) of amenable death rates between given timepoints. Findings Between 1990 and 2012, amenable mortality per 100 000 was highest in Scotland and lowest in England for both men and women; death rates fell in all countries, and the change accelerated after devolution. During 1990–2000, the greatest decline was seen in Northern Ireland (men RR 0·66, 95% CI 0·53–0·81; women 0·66, 0·53–0·81), and the lowest was seen in Wales (0·70, 0·56–0·87 and 0·74, 0·57–0·95, respectively). Similar patterns were seen during 2000–12, although the declines were larger than those for 1990–2000 in all four countries among both men and women, ranging from 0·50 (0·38–0·67) in Northern Ireland to 0·56 (0·43–0·74) in Wales (women in Northern Ireland 0·50, 0·36–0·69 and Scotland 0·65, 0·48–0·87). As a result of these mortality trends, differences in levels of amenable mortality between England and the other three countries narrowed between 1990 and 2012. Interpretation This study suggests that different NHS policies associated with political devolution has had little measurable effect on population health outcomes as measured by amenable mortality. An acceleration of the decline in amenable mortality since 2000 in all four countries might be indicative of an increase in the availability of resources for health care in each system. Funding Part funded by the Nuffield Trust and the Health Foundation.


      PubDate: 2014-11-21T03:03:31Z
       
  • Translating research into practice: a cross-sectional study using the
           Early Development Instrument to assess early years interventions in local
           level public health practice
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Rosemary Geddes , Lisa Marks Woolfson , Stephanie McNicol , Josephine N Booth , Steven Wray , Samantha Hardie , Larry Doi , John Frank
      Background Evidence that early years interventions can reduce inequalities has led to Scottish Government policy recommending that local areas implement initiatives to improve early child development. How best to measure the effects of these interventions is, however, unclear. We conducted a pilot study of the first UK use of the teacher-administered Early Development Instrument (EDI), an internationally validated measure of global child development now used at school entry in all children in Australia and most of Canada. Methods The study, conducted in the primary school setting in 2011–12, was cross-sectional in design and used qualitative and quantitative methods. During phase 1 the EDI was adapted for the Scottish context. 14 teachers assessed 154 pupils, using the instrument. Focus groups and semi-structured questionnaires were used to gather feedback from teacher participants on the instrument and the process. Phase 2 collected and analysed data from 1090 pupil participants, comprising 98% of eligible school-entrants in East Lothian local authority, assessed by 68 teachers. The 104-item EDI questionnaire has five domains of child development: physical, social, emotional, language and cognitive, and communication and general knowledge. Data were analysed with SPSS (version 17.0). The psychometric properties of the EDI were assessed with Cronbach's α. Mean scores in the domains were linked to levels of deprivation and results were mapped using Geographic Information System. Phase 3 monitored subsequent dissemination and use of EDI results. The study was approved by the School of Psychological Sciences and Health Ethics Committee of the University of Strathclyde, Glasgow, UK; the Education Authority of the relevant school district; and the Chief Scientist Office of the Scottish Government. In line with EDI data collection in other countries, opt-out consent was used for parents of pupils. All teachers provided written, informed consent. Findings Children in the most deprived quintile were 2·8 times more likely than the most affluent to be developmentally vulnerable in one or more domains; however, substantial developmental vulnerability was found across all five quintiles, not only in the most deprived. The EDI was found to be user friendly and acceptable to teachers, demonstrating high levels of internal reliability. Dissemination of results created a forum for multidisciplinary discussion and raised awareness about the importance of early child development, domains of development, and how inequalities can be tackled, leading to new initiatives based on EDI data. Interpretation The EDI is a robust instrument able to highlight developmental differences in children between socioeconomic groups and small-scale geographical areas. Its simplicity and usability lend themselves easily to community-wide implementation. Funding Medical Research Council and Chief Scientist Office of the Scottish Government.


      PubDate: 2014-11-21T03:03:31Z
       
  • How do Cumulative Impact Policies work' Use of institutional
           ethnography to assess local government alcohol policies in England
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Daniel Grace , Elizabeth McGill , Karen Lock , Matt Egan
      Background The Licensing Act (2003) gives English local authorities the power to implement Cumulative Impact Policies (CIPs), which are intended to strengthen licensing powers and limit the growth of on-premise and off-premise alcohol outlet density. Local authorities can now implement CIPs by designating boundaries within their borough as cumulative impact zones (CIZs) if adverse social effects of alcohol market saturation can be demonstrated. We are evaluating this intervention in a London borough, which as of January, 2013, had seven CIZs. Methods The qualitative arm of our study is informed by institutional ethnography. This sociological research tradition has had limited application in public health sciences despite obvious applicability to understanding processes of multilevel institutional regulation. We conducted semi-structured individual and group interviews with stakeholders (eg, licensing officers, councillors, police, trade), documentary analysis, and ethnographic data collection. Research participants were purposively selected to include diverse stakeholders from within our case study area as well as neighbouring boroughs with CIPs. We developed a detailed map to account for the ways in which different texts (eg, laws, policies, licensing forms) coordinate sequences of action related to alcohol licensing (eg, the work of granting or rejecting a licence application). Findings CIPs are an example of multilevel governance where national and local alcohol licensing priorities, interests, and legal powers interface. CIPs informed how some licensed premises conducted their business, including terms and conditions voluntarily adopted to minimise alcohol-related harms (eg, willingness to stop selling high-strength, inexpensive beer and cider). With newfound regulatory powers at the local level, came complex forms of work that local authorities had to negotiate, including assembling evidence and contesting licensing claims of applicants who sought to be granted new or modified licences. Interpretation Understanding the social and public health effects of CIPs requires innovative research strategies. Institutional ethnography offers important opportunities for methodological innovation in public health science. The map we developed reveals that CIPs must be viewed in relation to other alcohol initiatives. This qualitative research also generated nuanced questions about the social and public health effects of this alcohol intervention to which our ongoing quantitative analysis will contribute. Funding This work was supported by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR).


      PubDate: 2014-11-21T03:03:31Z
       
  • The effect of British Summer Time on outdoor physical activity
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Owen Haswell , Liam West , Bryn Savill , Robert Whitham , Rhodri Martin
      Background Physical inactivity is a major public health concern of recent times. The provision of opportunities for the population to be physically active is therefore a public health priority. Greater health benefits have been shown to be gained from being physically active outdoors. There is a sudden reduction in the available daylight evening hours at the end of British Summer Time (BST). This study aimed to assess the effect of this sudden reduction in daylight hours on levels of outdoor physical activity. Methods Data were collected by observation for 1 week before and 1 week after the end of BST (Oct 28, 2012) at Roath Park, Cardiff, Wales, a popular place for outdoor recreation. Observations were made between 0630 h and 0900 h and between 1700 h and 2000 h on every working day. Additionally observations were made between 1200 h and 1400 h on each Tuesday and Thursday. Data collection was done by one individual per observation period, who recorded the number and sex of individuals exercising at a specific location at the outdoor recreation area (categorised as walking, faster than walking, cycling). Findings The total number of observed exercisers in the week before and after the end of BST was 3668 and 3180, respectively. The mean total number of daily evening exercisers decreased significantly in the days after the end of BST (from 434·6 [SD 141·0] to 299·8 [105·3], 95% CI 207·5–392·1; p<0·0001), as did the number of morning exercisers (175·4 [47·4] to 135·8 [41·6], 99·3–172·3; p<0·0001). By contrast, the mean total number of people exercising between 1200 h and 1400 h increased from 309 (SD 39·2) to 501 (62·1) (95% CI 414·9–587·1, p<0·0001). Interpretation This preliminary study suggests that the number of people engaging in physical activity reduces abruptly after the end of BST, with reductions seen in both the evening and the morning observation timepoints. Despite the overall reduction in exercisers witnessed after the end of BST, there was a relative increase in the number of individuals engaged in activity at lunchtime. These changes suggest that daylight is an important determinant of outdoor physical activity behaviour. A larger study is warranted to explore the association between the determinants of the population's level of outdoor physical activity and available daylight hours. Funding None.


      PubDate: 2014-11-21T03:03:31Z
       
  • Risk of future harm in adolescents admitted to hospitals in England for
           injury related to victimisation, self-harm, or drug or alcohol misuse: a
           retrospective cohort study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Annie Herbert , Leah Li , Arturo Gonzalez-Izquierdo , Ruth Gilbert
      Background Injury related to adversity (ie, maltreatment, violence, self-harm, or drug or alcohol misuse) accounts for most mortality in adolescents. Targeting reduction of future harm in adolescents admitted to hospital with adversity-related injuries is of great public health interest in the UK. Evidence is lacking on the risks of emergency re-admission and death after an adolescent admission for adversity-related injury. We aimed to quantify these risks and to establish whether they are higher than those in adolescents with accident-related injury only. Methods We used linked Hospital Episode Statistics and Office for National Statistics mortality data for 10–19-year-old adolescents, who had at least one emergency admission for injury (the index admission; for multiple emergency admissions for injury, we randomly selected one) between April 1, 1997, and March 31, 2012. We conducted time-to-event analyses for emergency re-admission (non-injury or injury for any reason) or death before age 31 years, following the index. Findings Of 1 080 368 adolescents who had emergency admissions for injury, 335 103 (31·0%) had adversity-related injury at the index admission and 649 774 (60·1%) had accident-related injury. The cumulative incidence of an emergency re-admission 1 year from adversity-related injury was greater than that from an accident-related injury (girls 18·5% [95% CI 18·2–18·7%] vs 8·3 [8·2–8·5], boys 11·2 [11·0–11·3] vs 7·0 [6·9–7·0]), and remained about twice as high 5 and 10 years later. Rates of death within 1 year were greater after adversity-related injury (girls 114/100 000 [99–130] vs 52 [42–64], boys 201 [180–226] vs 56 [49–63]) and was twice to four times as high after 10 years. Relative hazards of re-admissions and death from adversity-related injury for girls and boys were higher than from accident-related injury by 1·65–2·16 times, adjusting for multiple re-admissions, age, chronic conditions, ethnicity, and socioeconomic status. Interpretation The risk of emergency re-admission or death from an adolescent admission for adversity-related injury is twice as high as that from accident-related injury. Since International Classification of Diseases 10 codes used were moderately sensitive for identifying adversity, the true relative risk could be higher than our estimates. Development of hospital-based interventions in adolescents with adversity-related injury, such as motivational interviewing, which has shown promise for reducing alcohol-related injury in the USA, could reduce this risk. Funding AH was supported by the Policy Research Unit in the Health of Children, Young People and Families, which is funded by the Department of Health Policy Research Programme (grant reference number 109/0001). AH is also supported by the University College London IMPACT studentship. The study funders played no part in the design, data analysis, and interpretation of this study, the writing of the manuscript, or the decision to submit the paper for publication. The authors' work was independent of their funders.


      PubDate: 2014-11-21T03:03:31Z
       
  • The push me, pull you of financial incentives and health inequalities: a
           mixed methods study investigating smoking cessation in pregnancy and
           breastfeeding
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Pat Hoddinott , Heather Morgan , Gillian Thomson , Nicola Crossland , Shelley Farrar , Deokhee Yi , Jenni Hislop , Victoria Hall Moran , Graeme MacLennan , Stephan U Dombrowski , Kieran Rothnie , Fiona Stewart , Linda Bauld , Anne Ludbrook , Fiona Dykes , Falko F Sniehotta , David Tappin , Marion K Campbell
      Background Financial incentives are increasingly considered to address socially patterned behaviours like smoking in pregnancy and breastfeeding. We investigated their mechanisms of action in relation to health inequalities to inform incentive intervention design. Methods The evidence syntheses we undertook were incentive effectiveness, delivery processes, barriers and facilitators to smoking cessation in pregnancy and also breastfeeding; and incentives for lifestyle behaviours. We searched Medline, Embase, CINAHL, PsycINFO, Web of Science, the Cochrane Library (all sections), MIDIRS, ASSIA, and the Trials Register of Promoting Health Interventions for studies published in English between Jan 1, 1990, and March 31, 2012, using a range of natural language, MeSH, and other index terms. Surveys were done with 1144 respondents from the general public and with 497 maternity and early-years health professionals. Qualitative interviews and focus groups were conducted with pregnant women, recent mothers, and partners in three UK settings (n=88); and with 53 service providers, 24 experts and decision makers, and 63 conference attendees. A discrete choice experiment (DCE) was conducted with 320 female current or ex-smokers. Findings Systematic reviews raised concerns about the reach of incentives, particularly to marginalised groups. Baseline characteristics for people who were eligible, approached, and recruited to studies were under-reported. Sample sizes were mostly small. Surveys revealed mixed acceptability. Less educated, white British, and women general public respondents disagreed (odds ratios [OR] 0·5≤OR<1·0) particularly with smoking cessation incentives. Universal incentives (55% net agreement) were preferred to targeting low income women (49% net agreement). DCE results showed that incentives, a quitting pal, and initial text or telephone support were statistically significant in increasing the reported likelihood that women would quit. Conflicting narratives of women's emotional, social and material environments and the push and pull of incentives were voiced. For some, unrestricted shopping vouchers offered rare opportunities for choice, reward for effort, and feeling valued amidst adversity. Women struggle on their own, even concealing behaviour, especially when people in personal networks smoke or formula feed. However layers of autonomy were revealed, with varying levels of resistance to the nanny state, and feeling judged, pressure, and stigma. How incentive interventions fit with life's challenges were incorporated into a logic model. Interpretation Financial incentives can help some women, but whether they will address inequalities is unclear because of concerns about reach and resistance to being pushed and pulled. Funding The project was funded by the Health Technology Assessment programme (10/31/02) and will be published in full in Health Technology Assessment. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates funds the Nursing Midwifery and Allied Health Professional Research Unit, University of Stirling; and the Health Services Research Unit and the Health Economics Research Unit, University of Aberdeen.


      PubDate: 2014-11-21T03:03:31Z
       
  • Participatory research with Travellers in Brighton
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Bryony Hughes
      Background Community engagement is important when addressing health inequalities. In recognition of this strategy, public health departments are commissioning participatory research. However, the involvement of communities as equal partners poses challenges for public health professionals. In this study, we explored these challenges using an example project with Travellers in Brighton. Methods The public health team worked with peer researchers to conduct primary qualitative research that focused on access to primary care and specialist health services. A commitment to a participatory approach informed all stages. The establishment of a partnership with the community was fundamental. Working through a third-sector organisation, two peer researchers with research experience and links across the community were identified. Training was provided to the peer researchers who conducted 15 semi-structured interviews with local Travellers. There was strong focus on reflective practice with ongoing evaluation of research tools and iterative data analysis. Findings The participatory approach had several advantages: it could access hard-to-reach subgroups (young men); allow exploration of stigmatised issues (mental health, infant mortality); and provide insights into how beliefs shaped health-seeking behaviour. Peer researchers ensured that recommendations were practical and specific. However, there were also challenges and limitations to this approach. Research that is fully owned by the community is not always realistic or practical. The project was initiated by the Council, with the public health team accountable for the results. That peer researchers often lacked confidence and sought direction from the perceived experts, highlights the difficulty in addressing power imbalances in a short timeframe and the need to clarify what level of participation is sought by the community. The peer researchers developed their interviewing technique, and transferred these skills to other roles. However, the rationale for consent, confidentiality, and accountability over expenses required repeated re-emphasis; this could be addressed by earlier involvement of peer researchers in budget planning and ethics approval. Interpretation Participatory research has potential to empower those involved and to lead to interventions that have an effect on socially excluded populations. However, there are justified concerns about academic rigour with limited guidance on how to overcome practical challenges. With increasing adoption of this approach, opportunities for sharing best practice need to be developed. Funding The project was funded by Brighton & Hove City Council (Communities and Equalities' team).


      PubDate: 2014-11-21T03:03:31Z
       
  • A new concept of health—implications for public health policy and
           practice: a qualitative analysis
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Marielle Jambroes , Trudi Nederland , Marian Kaljouw , Katja van Vliet , Marie-Louise Essink-Bot , Dirk Ruwaard
      Background In many developed countries ageing populations, growing health-care costs, and the rising burden of chronic diseases pose challenges for health systems and require innovations to improve and maintain population health. “Health as the ability to adapt and to self manage, in the face of social, physical and emotional challenges” was introduced as a new concept of health at an invitational conference in 2011, in reaction to the static nature and lack of realism of the 1948 WHO definition. Since this concept is one of the pillars of the innovation of the Dutch health-care professions and educational structure, we analysed the implications of this new concept for public health policy and practice. Methods We conducted focus group interviews (n=28) with stakeholders (n=277) in Dutch public health and health care (eg, physicians, nurses, policy makers, and patient organisations) on the pros and cons of this new concept in the light of a changing health-care system. We developed a framework of key themes within the interviews starting from WHO's essential public health operations and used a deductive approach to qualitative data analysis (Framework method) to analyse the interviews. Findings In reaction to the conceptualisation of adaptation and self-management, the participants perceived health as an individual asset and did not seem aware of the collective dimension, resulting in less attention paid to primary prevention programmes. Prevention was mainly mentioned in relation to primary and secondary care; health promotion was primarily regarded as an instrument to support individuals in adapting to a healthy lifestyle. However, adaptation and self-management could be supported by assuring governance for health and wellbeing through other sectors. Interpretation The new concept fits with the changing burden of disease and the contribution of individual behaviour to health outcomes. The main challenge of this concept for public health policy and practice will be to preserve primary prevention through the collective efforts of society. The main task will be to incorporate essential public health operations in the different sectors (health, housing, education, social policy) and to integrate public health in community care programmes. Funding The focus group interviews were funded by the National Health Care Institute, Netherlands. There was no external funding for the present analysis.


      PubDate: 2014-11-21T03:03:31Z
       
  • Association between cardiovascular risk factors and concurrent depressive
           symptoms in cardiometabolic disease: a cross-sectional study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Bhautesh Dinesh Jani , Jonathan Cavanagh , Sarah Barry , Geoff Der , Naveed Sattar , Frances S Mair
      Background Depression is two to three times more common in patients with cardiometabolic disease than in healthy individuals, but less is known about the association between cardiovascular risk factor values and depressive symptoms in these patients. We aimed to study the association between cardiovascular risk factors and concurrent depressive symptoms in patients with cardiometabolic disease. Methods Patients in Greater Glasgow, UK, with one of three cardiometabolic diseases—coronary heart disease, diabetes, or stroke—were screened for depression with the Hospital Anxiety and Depression Scale (HADS-D). The health board offered money incentives to primary care practitioners for depression screening. 125 143 patients with at least one cardiometabolic disease were on a primary care disease register during the 12-month observation period in 2008–09. 10 670 patients (8·5%) receiving treatment for depression were exempt from screening. HADS-D was recorded for 35 537 patients (31·1% of eligible), and the remaining 78 936 (68·9%) were not screened for unknown reasons. Four cardiovascular risk factors (systolic blood pressure, diastolic blood pressure, body-mass index, and total cholesterol) were recorded concurrently. A subset of patients with diabetes (n=18 453) also had HbA1c recorded concurrently. The association between each risk factor and probability of a positive HADS-D screening result (≥7) was analysed with logistic regression. Findings 7080 (19·9% of screened) had raised HADS-D. All four cardiovascular risk factors had a curvilinear J-shaped association with the probability of having a positive HADS-D; the nadirs (values with the lowest probability) were systolic blood pressure 149 mm Hg, diastolic blood pressure 77 mm Hg, body-mass index 26·75 kg/m2, and total cholesterol 3·67 mmol/L. In patients with diabetes, HbA1c had a J-shaped association with the probability of having a positive HADS-D, with an observed nadir of 7% DCCT (diabetes control and complications trial). All results remained significant after adjusting for age, sex, and socioeconomic status. Interpretation Patients with coronary heart disease, stroke, and diabetes had a higher probability of having symptoms of depression, for cardiovascular risk factor values at both extremes. These findings could have important implications for secondary prevention strategies and risk stratification, but further investigation is needed to determine the nature and direction of the observed association. Funding The study was funded by Chief Scientist Office, Scotland CAF/12/04. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the abstract.


      PubDate: 2014-11-21T03:03:31Z
       
  • Association of depression screening in cardiometabolic disease with future
           vascular events and mortality: a cohort study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Bhautesh Dinesh Jani , Charles Boachie , Colin McCowan , Sarah Barry , Jonathan Cavanagh , Frances S Mair
      Background Routine screening for depression in patients with cardiometabolic disease is advocated but its benefits remain unclear. We examined the association between such screening in a large UK cohort of patients with cardiometabolic diseases and all-cause mortality and vascular events at 4 years. Methods Patients in Greater Glasgow with one of three cardiometabolic diseases—coronary heart disease, diabetes, or stroke—underwent screening for depression with the Hospital Anxiety and Depression Scale (HADS-D). The health board offered monetary incentives for depression screening to primary care practitioners, and people with positive depression screens were treated (psychological or pharmacological) according to national guidelines. 125 143 patients with at least one of the diseases were listed on primary care registers during 12 months' observation in 2008–09. 10 670 (8·5%) receiving treatment for depression were exempt from screening. HADS-D was recorded for 35 537 patients (31·1% of eligible); the remaining 78 936 (68·9%) were not screened. We studied all-cause mortality and vascular events (using International Classification of Diseases 10 codes for myocardial infarction and stroke) by linking 124 414 patients (99·4%) on primary care registers to hospital discharge and mortality records for 4 years from April, 2009, and used Cox proportional hazards for survival analysis. Findings Mean age for the screened and unscreened population was 69 years (SD 11·9) and 67 years (14·3), respectively; 58% (20 658) of the screened population were men and 65·3% (22 726) belonged to a deprived socioeconomic group, compared with 54·2 % (42 727) and 67·4% (51 686), respectively, in the unscreened population. 4989 (6·3%) of 789 366 of the unscreened population were started on new antidepressants during the observation period compared with 1268 (3·5%) of 35 537 of the screened population and 572 of 7080 (8·02%) of those HADS-D positive. The screened population had lower all-cause mortality and vascular events than the unscreened population (hazard ratio 0·74, 95% CI 0·72–0·77, p<0·0001 vs 0·69, 0·67–0·72, p<0·0001) at 4 years. Results remained significant after adjusting for age, sex, socioeconomic status, and comorbidity. Interpretation Screening for depression was associated with a reduction in all-cause mortality and vascular events in patients with cardiometabolic diseases. The uptake of screening was poor for unknown reasons. The possibility of reverse causality and the possible confounding effect of disease severity are important limitations. Further research to determine reproducibility and explore underlying mechanisms is merited. Funding The study was funded by BUPA Foundation. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the abstract.


      PubDate: 2014-11-21T03:03:31Z
       
  • Systematic reviews and meta-analyses on the effects of active and passive
           smoking on respiratory health outcomes: the SmokeHaz online resource
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Leah Jayes , John Britton , Constantine Vardavas , Jo Leonardi-Bee
      Background Active and passive smoking increases the risk of respiratory disease in adults and children, but communication of the magnitude of these effects in a manner that is accessible and usable by public and policy makers presents a challenge. We have therefore developed a unique online resource, SmokeHaz, which summarises the effect of smoking on a range of health outcomes, focusing on respiratory diseases. Methods We conducted a series of definitive systematic reviews and meta-analyses of longitudinal, nested case-control, and cohort studies. We identified eligible studies using electronic databases (Medline, Embase, and Web of Science, published from 1985 to 2013), conference proceedings, websites, reference lists of reviews and studies, and through contact with experts. No language restrictions were imposed. Random effect meta-analyses were used to pool the findings. Heterogeneity was explored with subgroup analyses, and publication bias was assessed with funnel plots. Findings We included a total of 216 articles, none of which disclosed tobacco industry funding. Our reviews confirmed substantially increased risks of lung cancer (risk ratio 10·9, 95% CI 8·3–14·4, n=34), chronic obstructive pulmonary disease (4·0, 3·2–5·1, n=22), and asthma (1·6, 1·1–2·4, n=8) among adult smokers, though these effects were all strongly related to quantity smoked. Exposure to passive smoking significantly increased the risk of several respiratory diseases in childhood, including asthma, wheeze, lower respiratory infections, and reduced lung function, and in adults lung cancer (1·4, 1·2–1·7, n=13). In addition to these expected findings, our reviews showed that active smoking significantly increased the risk of asthma exacerbations, sleep apnoea (2·0, 1·02–3·8 n=2), and tuberculosis (1·6, 1·2–2·1, n=4), and that passive smoking increased the risk of tuberculosis in adults (1·44, 1·02–2·01, n=2). Interpretation The findings from the systematic reviews have been translated into easily digestible content and published on the SmokeHaz website. We are now evaluating the effectiveness, usability, and accessibility of the website for the public and policy makers. Funding The research has been independently funded by the European Respiratory Society (ERS) and has been carried out by the UK Centre for Tobacco and Alcohol Studies, with the oversight of the ERS Tobacco Control Committee. The content of the website has been approved by the Executive Committee of ERS and developed by the European Lung Foundation.


      PubDate: 2014-11-21T03:03:31Z
       
  • Social return on investment analysis of an art group for people with
           dementia
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Carys Jones , Rhiannon Tudor Edwards , Gill Windle
      Background Funding bodies require interventions to show value for money before further investment is made. Although cost-effectiveness analysis is widely used in economic evaluation it might not capture the social value generated by certain interventions. Here, we describe Social Return on Investment (SROI) analysis of the Dementia and Imagination study. SROI is similar to cost–benefit analysis in that inputs and outputs are converted into a monetary value; however, SROI also attempts to capture the social value generated. Although SROI has been used in the education and non-profit sectors, it is still relatively unused for the evaluation of health and social care interventions, partly because the valuation of outputs can be subjective. Methods The intervention will be delivered between June, 2014, to May, 2015, and involves people with dementia attending weekly art sessions for 3 months. An uncontrolled, cohort study design is being used. There will be three settings: the community, residential care homes, and inpatient assessment units. Participants will be interviewed at baseline, 3 months, and 6 months. SROI analysis involves six steps: establishing scope and identifying stakeholders, mapping outcomes, evidencing and valuing outcomes, establishing impact, calculating the SROI, and reporting it as a ratio of £X of social value generated for every £1 invested. The primary indicator for participant wellbeing is the DEMQOL; staff attitudes will be measured with the Approaches to Dementia Questionnaire. Semi-structured interviews will be conducted with participants, families, and staff involved with the project to capture broader outcomes. Findings We identified three key stakeholders: participants, participants' families, and staff at residential units where the project is taking place. Our next challenge is to assign a monetary value to non-physical outcomes such as increased wellbeing, increased confidence in participants, and increased staff morale. Interpretation SROI is an attempt to move towards broader economic evaluation in interventions that aim to have a wider effect on wellbeing than on health alone. The non-controlled study design would be a limitation for traditional cost-effectiveness analysis; however, establishing the effect through considering attribution, displacement, and drop-off are key parts of SROI analysis and are used to minimise the risk of overinterpreting the effect of the intervention. Funding Dementia and Imagination was funded as Dementia and imagination: connecting communities and developing well-being through socially engaged visual arts practice, grant ref AH/K00333X/1, by the AHRC and ESRC as a part of the Cross-Council Connected Communities Programme.


      PubDate: 2014-11-21T03:03:31Z
       
  • Improving measurement of the distribution of alcohol consumption across
           locations, beverages, and drinkers in England and Scotland: a
           cross-sectional telephone survey
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Jessica Li , John Holmes , Petra Meier , Anne Marie MacKintosh
      Background Most UK estimates of alcohol consumption come from population-based surveys, which estimate mean weekly consumption by beverage type, but underestimate total consumption compared with sales data. This study aimed to use data collected via a novel survey method developed in New Zealand, recording beverage-specific consumption by location to better understand where and how alcohol is consumed by drinkers in England and Scotland. Methods Between September, 2012, and February, 2013, 3477 adult drinkers (aged 16–65 years) divided evenly between England and Scotland were recruited through random digit dialling. They were interviewed via a cross-sectional landline telephone survey with consumption recorded for 13 alcoholic beverages at 14 locations (measures validated through cognitive interviewing). Through this novel method, a quantity-frequency measure of self-reported units of alcohol consumed within the past 6 months by beverage and location was derived. Descriptive statistical analyses describe how total units consumed were distributed across six locations, five beverage types, and demographic groups. Data were weighted to reflect the age, sex, and employment-status of English and Scottish drinkers. Findings Over half (62%) of all alcohol consumed by English and Scottish respondents was within their own or someone else's home. Roughly a quarter of all alcohol consumed at home was wine. Most alcohol consumed by men was beer whereas women drank more wine. Only 24% of all alcohol was consumed in pubs, bars, and nightclubs, and just 12% of all alcohol was consumed by harmful drinkers in these locations, the primary focus of policy concern. Interpretation UK alcohol issues are often framed in terms of binge drinking in on-trade settings (pubs, bars). We found that most drinking occurs in people's own homes. Through its novel method of improving participants' recall of drinking through its breakdown of consumption into multiple locations, our survey underestimated the level of drinking to a much smaller degree than previous estimates when compared with sales data. The identification of the places and contexts of risky drinking can allow for public health interventions aimed at reducing alcohol-related harms in locations such as the home (eg, altering container sizes, televised advertising) to be more targeted to drinking patterns of concern. Funding Medical Research Council National Prevention Research Initiative (MR/J000523/1).


      PubDate: 2014-11-21T03:03:31Z
       
  • Social and lifestyle characteristics and burden of ill-health associated
           with self-reported hearing and vision impairments in older men in the
           British community: a cross-sectional study
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Ann E M Liljas , S Goya Wannamethee , Olia Papacosta , Kate Walters , Lucy T Lennon , Livia A Carvalho , Sheena E Ramsay
      Background Sensory impairment is common in older adults and we need to understand more about its association with other health conditions. We explored sensory impairment in relation to demographic, lifestyle factors, and health conditions in older men. Methods In a cross-sectional study, 3981 men aged 63–85 years (82% of participants recruited to the British Regional Heart Study cohort in 1978–80 and still alive in 2003) were selected from general practices in 24 British towns. Data on hearing aid use and ability to follow television at a volume others find acceptable allowed for four categories of hearing: can hear (n=2851), can hear with an aid (n=482), cannot hear and no aid (n=424), and cannot hear despite an aid (n=168). Vision impairment was defined as not being able to recognise a friend across a road (n=124). Logistic regression was used to investigate associations of hearing impairment and vision impairment with self-reported doctor-diagnosed coronary heart disease, disability (difficulty taking the stairs, difficulty keeping balance), social interaction (attending few social activities), and quality of life (experiencing pain, feeling anxious or depressed). Findings 1074 men (27%) reported hearing impairment and 124 (3%) reported vision impairment. Compared with those reporting no hearing problem, hearing impairment was associated with disability, poor social interaction, and poor quality of life. Poor quality of life remained significant after having adjusted for social class, smoking, obesity, and physical activity. Only men who could not hear despite having a hearing aid were more likely to report coronary heart disease (age-adjusted odds ratio 1·89, 95% CI 1·36–2·63) and falls (1·62, 1·05–2·48). Vision impairment was associated with symptoms of coronary heart disease including chest pain (1·58, 1·07–2·40) and breathlessness (2·06, 1·38–3·06), but not with diagnosed coronary heart disease (1·39, 0·93–2·07). Vision impairment was also significantly associated with falls, poor quality of life, poor social interaction, and disability, which remained significant after adjusting for social class, smoking, obesity, and physical activity. Men with a sensory impairment were more likely to be physically inactive, obese (hearing impairment only), and in a manual social class. Interpretation Older men with hearing impairment and vision impairment have a high risk of disability, poor health, and poor social interaction. Policy efforts for early detection and treatment of sensory impairment could be crucial for independent living in old age. Funding The British Regional Heart Study is funded by the British Heart Foundation. AEML is funded by the National Institute for Health Research School for Public Health Research. SER is funded by a UK Medical Research Council Fellowship.


      PubDate: 2014-11-21T03:03:31Z
       
  • Environmental conservation activities for health: building on systematic
           review methods to consider a disparate, dispersed, and limited evidence
           base
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Rebecca Lovell , Kerryn Husk , Chris Cooper , Will Stahl-Timmins , Ruth Garside
      Background Actions taken to enhance and conserve the outdoor environment offer opportunities to improve the health and wellbeing of people taking part in those activities and of those who are exposed to the improved environments. Both health and environmental organisations have used conservation activities as health promotion interventions; however evidence of effect is disparate, dispersed, and limited and therefore requires novel approaches to evidence synthesis. Our aim was to systematically review the evidence and then build on the results to consider if, how, for whom, and in what contexts environmental conservation activities are beneficial to those taking part. Methods After a theory-driven, mixed-method systematic review, a conceptual model was derived from the results of the primary synthesis to illustrate mechanisms of change and the role of mediators, moderators, and feedback loops that might have led to or influenced health gain. Because of the nature of the primary evidence the plausibility of key pathways was then assessed through the identification and application of further high level evidence. Since the evidence was highly dispersed, a multistage extended search strategy of academic and grey literature was used. 27 databases spanning health, social, and geographical sciences were searched for studies published in English between Jan 1, 1990, and Oct 1, 2012. 13 quantitative and 13 qualitative studies were identified. Findings Although the results were largely inconclusive there was some evidence of positive effects in six of the quantitative studies to physiological, mental, and emotional health outcomes. The qualitative evidence suggested that positive experiences contribute to quality of life, particularly for marginalised groups. The benefits of these complex interventions operate through complex pathways and might differ between individual participants. The potential mechanisms, through which positive health and wellbeing benefits can occur, such as reducing social isolation and increasing levels of physical activity, are well supported by existing high level research. Interpretation Conservation activities can offer a win-win situation, with potential to improve both the environment and health and wellbeing through one delivery mechanism. Although the extended review process maximised the available evidence, further robust research is needed. Funding This research and the original systematic review were funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR). The European Centre for Environment and Human Health (part of the University of Exeter Medical School) is part financed by the European Regional Development Fund Programme 2007 to 2013 and European Social Fund Convergence Programme for Cornwall and the Isles of Scilly.


      PubDate: 2014-11-21T03:03:31Z
       
  • Point-of-care testing versus standard practice for chlamydia: a new
           approach to assessing the public health effect of rapid testing and
           treatment at local level
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Catherine M Lowndes , Ellie Sherrard-Smith , Ciara Dangerfield , Yoon H Choi , Nathan Green , Mark Jit , Rob D Marshall , Catherine Mercer , Emma Harding-Esch , Anthony Nardone , Rebecca Howell-Jones , John Bason , Owen A Johnson , Christopher P Price , Charlotte A Gaydos , S Tariq Sadiq , Peter J White
      Background Chlamydia trachomatis is the most commonly diagnosed bacterial sexually transmitted infection in Britain. Present standards specify treatment within 14 days of testing positive; point-of-care testing (POCT) can eliminate this delay and potentially reduce loss to follow-up; its greater convenience might increase testing. 90-min nucleic acid amplification tests are the best available POCTs for chlamydia, with alternatives under development. However, cost-effectiveness depends on cost-per-test, sensitivity and specificity, and the effect of POCT on transmission. Methods We developed a user-friendly web-based method, based on a transmission-dynamic model for chlamydia, to assess the epidemiological impact and cost-effectiveness of introducing POCT in different local settings. The model uses behavioural and prevalence data from the National Survey of Sexual Attitudes and Lifestyles, and Public Health England surveillance data; these data inform on local-level variation, which is represented by sampling parameter values from within their ranges of uncertainty and selecting parameter sets that reproduce local coverage and diagnosis rates. The user can select different local settings, and vary sensitivity and specificity for the tests, specify costs (fixed and unit costs, including staff time), and then assess the effect of introducing POCT in different clinical services by comparison with a situation with no POCT. In the model, presumptive treatment is represented, which we expect to be reduced with the introduction of POCT because test results would be rapidly available to guide treatment. Findings Changes in numbers of infections and diagnoses occurring under different scenarios (including conventional testing) were estimated, with uncertainty ranges, allowing calculation of total costs, and cost per infection (and serious sequelae) averted, while accommodating the considerable variation in chlamydia testing coverage, positivity, and diagnosis rates. Potential changes in sexual behaviour between test and treatment could determine the relative contribution of increased treatment rates and reduced treatment delay to the reduction in prevalence as a consequence of POCT. Interpretation The effect of POCT was dependent on both the test performance characteristics and the assumptions about the implementation of the test across local services. Exploration of many uncertainties surrounding chlamydia epidemiology and screening implementation is possible with this model. This method can complement local and national knowledge, and contribute to local-level management of chlamydia infection. Funding Innovate UK (Technology Strategy Board), UK Medical Research Council, and the National Institute for Health Research. The Electronic Self-Testing Instruments for Sexually Transmitted Infection (eSTI2) Consortium eSTI2 is Funded under the UKCRC Translational Infection Research (TIR) Initiative supported by the Medical Research Council (Grant Number G0901608) with contributions to the Grant from the Biotechnology and Biological Sciences Research Council, the National Institute for Health Research on behalf of the Department of Health, the Chief Scientist Office of the Scottish Government Health Directorates, and the Wellcome Trust


      PubDate: 2014-11-21T03:03:31Z
       
  • The communication of systematic review research findings: a randomised
           experiment of whether readers can understand the key messages from
           summaries of Cochrane reviews without reading the full review
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Lisa Maguire , Mike Clarke
      Background Cochrane reviews provide an important source of evidence. Many readers will only access the various summaries available for Cochrane reviews rather than the full reviews, so it is essential that the summaries are clear and understandable. We explored whether readers could understand key messages without having to read the full review, and whether there were differences in understanding between various types of summary. Methods In August, 2013, we conducted a randomised prospective experiment to determine readers' effectiveness of retrieving information from summaries of systematic reviews provided by the Cochrane Library. Participants were a convenience sample of 36 members of university staff. We focused on one review, which assessed the health effects of the use of electric fans during heat waves. We selected this review because of its topical nature, in that we were experiencing hot weather in August. Participants were asked about their expectation of the effect on mortality of using electric fans during heat waves. They were then randomly assigned to reading one of four summaries of the review (ie, abstract, plain language, podcast, or podcast transcript) and asked to spend no more than 15 min reading or listening to the summary. Afterwards they gave their opinion on the effect of electric fans on mortality and whether they would want to read the full review. The main outcome measure was the correct identification of a key review outcome, which was that the research evidence is mixed. Findings Of the 36 participants, nine received the abstract, eight the plain language summary, eight the transcript, and 11 the podcast. After considering their summary, 20 participants (53%) identified what the authors of the review regarded as its key message on mortality (three participants [33%] in the abstract group, four [50%] in each of the plain language and transcript groups, and nine [78%] in the podcast group). The differences between these groups were not statistically significant (p=0·31, Fisher's exact test). Only 13 (37%) of the respondents said that they would want to read the full review after having considered their summary. Interpretation The differences between the groups were not statistically significant but suggest that the audio summary might improve knowledge transfer compared with written summaries. Further research should incorporate a larger sample size, and use more than one review alongside qualitative research to understand how people engage with summaries. Funding None.


      PubDate: 2014-11-21T03:03:31Z
       
  • Attitudes and preferences towards screening for dementia: a systematic
           review
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Steven Martin , Sarah Kelly , Sarah Cullum , Tom Dening , Greta Rait , Chris Fox , Cornelius Katona , Carol Brayne , Louise Lafortune
      Background Population screening might provide a mechanism to enable early detection of dementia. Yet the potential benefits, harms, or acceptability of such a large-scale intervention are not well understood. We conducted a systematic review of the international scientific literature to examine the attitudes and preferences of the general public, health-care professionals, people with dementia, and their carers towards population screening for dementia. Methods We searched 15 bibliographic databases (up to July 12, 2012, no language restriction) using wide-ranging terms related to dementia, screening, case-finding, and attitudes and preferences towards testing in primary or community care settings; genetic screening and biomarkers were excluded. All study designs were included except opinion-based papers. Included papers were doubly quality assessed and thematically analysed with NVivo (version 9). The review adheres to the PRISMA checklist. Findings 29 910 articles were identified of which 30 met the inclusion criteria. We identified 17 themes relating to the three phases of the screening process (pre-screen, in-screen, and post-screen), none of which emerged as more of a facilitator than a barrier to the acceptance of dementia screening. Seven themes emerged in relation to the patient, carer, and general population: existing health state, lifestyle and life view, awareness of dementia, role of clinician, communication, benefit, and role of the family. Ten themes emerged in relation to the clinician and health-care professional: the patient's existing health and comorbidities, awareness of dementia, confidence, duration of patient contact, suitability of screening method, cost, disclosure, time, treatment and prognosis, and stigma. Interpretation As for all screening programmes, screening for dementia raises complex issues around preference and choice for clinicians and the public; the specific factors that promote or reduce screening acceptance the most are unclear. Overall, the level of evidence is low, few large scale studies have been undertaken, but none were conducted in representative samples, all affecting the generalisability of identified themes across health-care contexts. Nevertheless, our findings suggest that population screening for dementia might not be acceptable to either the general public or health-care professionals, and highlight where focused efforts are needed to gain insights into dementia specific issues. Funding This article presents independent research cofunded by the Alzheimer's Society (project grant 129) and The BUPA Foundation, and supported by National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care for Cambridgeshire and Peterborough.


      PubDate: 2014-11-21T03:03:31Z
       
  • Assessment of liver disease in Tower Hamlets, London, UK: foundation for
           integrated solutions
    • Abstract: Publication date: 19 November 2014
      Source:The Lancet, Volume 384, Supplement 2
      Author(s): Ailsa McKay , Andrew Tang , Durka Dougall , Caroline Rumble , Somen Banerjee
      Background Although most liver disease is preventable and rates are falling across Europe, morbidity and mortality are increasing in England. The London Borough of Tower Hamlets has one of the highest liver disease mortality rates in England (29·1/100 000 compared with 18·9/100 000 national average). We undertook a collaborative needs assessment with our local clinical commissioning group to better understand this local problem and identify priorities for intervention. Methods Data collation and descriptive analysis of information from primary care, secondary care, public health, and national sources were conducted over 6 months during 2013–14. The disease burden, common causes, and trends were identified, with particular focus on at-risk population groups. Service provision was reviewed and measured against need. Two-stage stakeholder engagement was undertaken: initial consultation with key partners and subsequent borough-wide consultation. Findings Alcohol-related disease, non-alcoholic fatty liver disease, and viral hepatitis all contributed to local burden of disease. Tower Hamlets had the highest rates of cirrhosis admissions and liver cancer mortality in England. There were increasingly high rates of alcohol-related admissions (2290/100 000 vs 1912/100 000 for London and 1895/100 000 for England). 51% of the Tower Hamlets population (133 989/262 723, based on 2012 census estimates) were non-alcohol drinkers, but 43% of alcohol drinkers exhibited harmful drinking patterns. We noted high levels of obesity (30% in adults) and diabetes (6·1% prevalence, rapidly rising), proxy measures for non-alcoholic fatty liver disease. We found high rates of hepatitis B infection (incidence per 100 000, 2·38 vs 1·04 nationally) and hepatitis C infection (fourth highest rate nationally [1089/100 000], despite high rates of underdiagnosis). Important factors included ethnicity, deprivation, population movement, and hazardous alcohol use in subgroups. Although specialist services exist for all major disease subtypes, we found evidence of mismatch between service targeting and high-risk groups, and underdeveloped service integration. Interpretation Complex factors contribute to the picture of liver disease in Tower Hamlets. For example, high rates of hazardous alcohol use within some population groups are masked by high abstinence rates among others (such as the large Bangladeshi population). Insights from this work have facilitated the development of a joined-up tailored approach to address various contributing components. We are working with partners to develop clear care pathways, improve service provision, increase hepatitis screening, and consider universal hepatitis B immunisation in areas of high prevalence. Funding None.


      PubDate: 2014-11-21T03:03:31Z
       
 
 
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