Reader in Public Health (Evidence Synthesis)
areas of expertise
Holidays, celebrations, and commiserations: measuring drinking during feasting and fasting to improve national and individual estimates of alcohol consumption
BMC Medicine, 13:113, 2015.
Abstract: Background: Accurate measures of alcohol consumption are critical in assessing health harms caused by alcohol. In many countries, there are large discrepancies between survey-based measures of consumption and those based on alcohol sales. In England, surveys measuring typical alcohol consumption account for only around 60% of alcohol sold. Here, using a national survey, we measure both typical drinking and atypical/special occasion drinking (i.e., feasting and fasting) in order to develop more complete measures of alcohol consumption. Methods: A national random probability telephone survey was implemented (May 2013 to April 2014). Inclusion criteria were resident in England and aged 16 years or over. Respondents (n = 6,085) provided information on typical drinking (amounts per day, drinking frequency) and changes in consumption associated with routine atypical days (e.g., Friday nights) and special dinking periods (e.g., holidays) and events (e.g., weddings). Generalized linear modelling was used to identify additional alcohol consumption associated with atypical/special occasion drinking by age, sex, and typical drinking level. Results: Accounting for atypical/special occasion drinking added more than 120 million UK units of alcohol/week (~12 million bottles of wine) to population alcohol consumption in England. The greatest impact was seen among 25- to 34-year-olds with the highest typical consumption, where atypical/special occasions added approximately 18 units/week (144 g) for both sexes. Those reporting the lowest typical consumption (≤1 unit/week) showed large relative increases in consumption (209.3%) with most drinking associated with special occasions. In some demographics, adjusting for special occasions resulted in overall reductions in annual consumption (e.g., females, 65 to 74 years in the highest typical drinking category). Conclusions: Typical drinking alone can be a poor proxy for actual alcohol consumption. Accounting for atypical/special occasion drinking fills 41.6% of the gap between surveyed consumption and national sales in England. These additional units are inevitably linked to increases in lifetime risk of alcohol-related disease and injury, particularly as special occasions often constitute heavy drinking episodes. Better population measures of celebratory, festival, and holiday drinking are required in national surveys in order to adequately measure both alcohol consumption and the health harms associated with special occasion drinking.
Relationship between alcohol-attributable disease and socioeconomic status, and the role of alcohol consumption in this relationship: a systematic review and meta-analysis
BMC Public Health, 15:400, 2015.
Abstract: Background: Studies show that alcohol consumption appears to have a disproportionate impact on people of low socioeconomic status. Further exploration of the relationship between alcohol consumption, socioeconomic status and the development of chronic alcohol-attributable diseases is therefore important to inform the development of effective public health programmes. Methods: We used systematic review methodology to identify published studies of the association between socioeconomic factors and mortality and morbidity for alcohol-attributable conditions. To attempt to quantify differences in the impact of alcohol consumption for each condition, stratified by SES, we (i) investigated the relationship between SES and risk of mortality or morbidity for each alcohol-attributable condition, and (ii) where, feasible explored alcohol consumption as a mediating or interacting variable in this relationship. Results: We identified differing relationships between a range of alcohol-attributable conditions and socioeconomic indicators. Pooled analyses showed that low, relative to high socioeconomic status, was associated with an increased risk of head and neck cancer and stroke, and in individual studies, with hypertension and liver disease. Conversely, risk of female breast cancer tended to be associated with higher socioeconomic status. These findings were attenuated but held when adjusted for a number of known risk factors and other potential confounding factors. A key finding was the lack of studies that have explored the interaction between alcohol-attributable disease, socioeconomic status and alcohol use. Conclusions: Despite some limitations to our review, we have described relationships between socioeconomic status and a range of alcohol-attributable conditions, and explored the mediating and interacting effects of alcohol consumption where feasible. However, further research is needed to better characterise the relationship between socioeconomic status alcohol consumption and alcohol-attributable disease risk so as to gain a greater understanding of the mechanisms and pathways that influence the differential risk in harm between people of low and high socioeconomic status.
Adverse childhood experiences and associations with health-harming behaviours in young adults: surveys in the European Region
Professor Mark Bellis, Professor Karen Hughes, Nicola Leckenby, Lisa Jones, Adriana Baban, Margarita Kachaeva, Robertas Povilaitis, Iveta Pudule, Gentiana Qirjako, Betul Ulukol, Marija Raleva, Natasa Terzic
Bulletin of the World Health Organization, Online first format, 2014.
Abstract: Objective To evaluate the association between adverse childhood experiences – e.g. abuse, neglect, domestic violence and parental separation, substance use, mental illness or incarceration – and the health of young adults in the eastern European Region. Methods: Between 2010 and 2013, adverse childhood experience surveys were undertaken in Albania, Latvia, Lithuania, Montenegro, Romania, the Russian Federation, The former Yugoslav Republic of Macedonia and Turkey. There were 10’696 respondents – 59.7% female – aged 18–25 years. Multivariate modelling was used to investigate the relationships between adverse childhood experiences and health-harming behaviours in early adulthood including substance use, physical inactivity and attempted suicide. Findings: Over half of the respondents reported at least one adverse childhood experience. Having one adverse childhood experience increased the probability of having other adverse childhood experiences. The number of adverse childhood experiences was positively correlated with subsequent reports of harming behaviours. Compared with those who reported no adverse experiences, respondents who reported at least four adverse childhood experiences were at significantly increased risk of many health-harming behaviours, with odds ratios varying from 1.68 (95% confidence interval (CI): 1.32–2.15) – for physical inactivity – to 48.53 (95% CI: 31.98–76.65) – for attempted suicide. Modelling indicated that prevention of adverse childhood experiences would substantially reduce the occurrence of many health-harming behaviours within the study population. Conclusion: Our results indicate that individuals who do not develop health-harming behaviours are more likely to have experienced safe, nurturing childhoods. Evidence-based programmes to improve parenting and support child development need large-scale deployment in the eastern European Region.
Views and experiences of hepatitis C testing and diagnosis among people who inject drugs: Systematic review of qualitative research
Int J Drug Policy., 21st November, 2013.
Abstract: Background: Many developed countries are facing a major challenge to improve identification of individuals acutely and chronically infected with hepatitis C virus (HCV) infection. We explored the views and experiences of people who inject drugs (PWID) in relation to HCV testing, and diagnosis through a review and synthesis of qualitative research. Methods: Based on the thematic synthesis of qualitative research. Searches were conducted in 14 databases and supplemented by reference checking, hand searching of selected journals, and searches of relevant websites. Studies of any qualitative design that examined the views and experiences of, and attitudes towards, HCV testing and diagnosis among PWID or practitioners involved in their care were included. Key themes and sub-themes were systematically coded according to the meaning and content of the findings of each study which proceeded to the preparation of a narrative account of the synthesis. Results: 28 qualitative studies were identified. We identified a number of overarching descriptive themes in the literature, finding overall that PWID hold complex and differing views and experiences of testing and diagnosis. Three major themes emerged: missed opportunities for the provision of information and knowledge; shifting priorities between HCV testing and other needs; and testing as unexpected and routine. Evidence of missed opportunities for the provision of knowledge and information about HCV were clear, contributing to delays in seeking testing and providing a context to poor experiences of diagnosis. Influenced by the nature of their personal circumstances, perceptions of the risk associated with HCV and the prioritisation of other needs acted both to encourage and discourage the uptake of HCV testing. Undergoing HCV testing as part of routine health assessment, and an unawareness of being testing was common. An unexpected positive diagnosis exacerbated anxiety and confusion. Conclusion: This review has identified that there are modifiable factors that affect the uptake of HCV testing and experiences of HCV diagnosis among PWID. Intervention development should focus on addressing these factors. There is a need for further research that engages PWID from a diverse range of populations to identify interventions, strategies and approaches that they consider valuable.
Effectiveness of interventions to increase hepatitis C testing uptake among high-risk groups: a systematic review
The European Journal of Public Health, 24/10/2013.
Abstract: Background: People who inject drugs are at the greatest risk of acquiring hepatitis C virus infection in many high-income countries, including those in Europe. Our review examined the effectiveness of interventions aimed at increasing hepatitis C virus testing uptake. Methods: We undertook a systematic review of controlled studies. Searches of 13 databases were supplemented with citation searching, and manual searches of reference lists and websites. Studies of interventions that aimed to increase testing uptake among high-risk groups were included. Testing uptake was our primary outcome measure of interest and secondary outcomes were engagement in follow-up services and treatment. A narrative synthesis was undertaken. Results: Eight controlled studies were included. Three studies examined interventions in primary care; one examined dried blood spot testing as an alternative method of testing, and two examined outreach provision. Two further studies examined interventions to improve hepatitis C management. Targeted case finding in primary care, support and training for primary care practitioners, offering alternative testing and provision of outreach testing all increased uptake of testing; however, intervention effects were variable. Conclusions: Evidence from the available studies suggests that increases in testing uptake can be achieved. Careful attention needs to be paid to the resource implications associated with implementation of interventions in primary care settings and also of the potential for interventions to improve outcomes once a positive diagnosis has been made. Further research on the cost-effectiveness of the intervention approaches examined in this review is required.
Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies.
The Lancet, 379, 1621-1629, 2012, doi:10.1016/S0410-6736(11)61851-5..
Abstract: Background: About 15% of adults worldwide have a disability. These individuals are frequently reported to be at increased risk of violence, yet quantitative syntheses of studies of this issue are scarce. We aimed to quantify violence against adults with disabilities. Methods: In this systematic review and meta-analysis, we searched 12 electronic databases to identify primary research studies published between Jan 1, 1990, and Aug 17, 2010, reporting prevalence estimates of violence against adults (aged mainly ≥18 years) with disabilities, or their risk of violence compared with non-disabled adults. We included only studies reporting violence occurring within the 12 months before the study. We assessed studies with six core quality criteria, and pooled data for analysis. Findings: Of 10 663 references initially identified, 26 were eligible for inclusion, with data for 21 557 individuals with disabilities. 21 studies provided data suitable for meta-analysis of prevalence of violence, and ten for meta-analysis of risks of violence. Pooled prevalence of any (physical, sexual, or intimate partner) recent violence was 24·3% (95% CI 18·3—31·0) in people with mental illnesses, 6·1% (2·5—11·1) in those with intellectual impairments, and 3·2% (2·5—4·1) in those with non-specific impairments. We identified substantial heterogeneity in most prevalence estimates (I2 >75%). We noted large uncertainty around pooled risk estimates. Pooled crude odds ratios for the risk of violence in disabled compared with non-disabled individuals were 1·50 (95% CI 1·09—2·05) for all studies combined, 1·31 (0·93—1·84) for people with non-specific impairments, 1·60 (1·05—2·45) for people with intellectual impairments, and 3·86 (0·91—16·43) for those with mental illnesses. Interpretation: Adults with disabilities are at a higher risk of violence than are non-disabled adults, and those with mental illnesses could be particularly vulnerable. However, available studies have methodological weaknesses and gaps exist in the types of disability and violence they address. Robust studies are absent for most regions of the world, particularly low-income and middle-income countries. Funding: WHO Department of Violence and Injury Prevention and Disability.
Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies
Lancet, 380, 899-907, 2012.
Abstract: Background: Globally, at least 93 million children have moderate or severe disability. Children with disabilities are thought to have a substantially greater risk of being victims of violence than are their non-disabled peers. Establishment of reliable estimates of the scale of the problem is an essential first step in the development of effective prevention programmes. We therefore undertook a systematic review and meta-analysis to synthesise evidence for the prevalence and risk of violence against children with disabilities. Methods: For this systematic review and meta-analysis, we searched 12 electronic databases to identify cross-sectional, case-control, or cohort studies reported between Jan 1, 1990, and Aug 17, 2010, with estimates of prevalence of violence against children (aged ≤18 years) with disabilities or their risk of being victims of violence compared with children without disabilities. Findings: 17 studies were selected from 10 663 references. Reports of 16 studies provided data suitable for meta-analysis of prevalence and 11 for risk. Pooled prevalence estimates were 26·7% (95% CI 13·8—42·1) for combined violence measures, 20·4% (13·4—28·5) for physical violence, and 13·7% (9·2—18·9) for sexual violence. Odds ratios for pooled risk estimates were 3·68 (2·56—5·29) for combined violence measures, 3·56 (2·80—4·52) for physical violence, and 2·88 (2·24—3·69) for sexual violence. Huge heterogeneity was identified across most estimates (I2>75%). Variations were not consistently explained with meta-regression analysis of the characteristics of the studies. Interpretation: The results of this systematic review confirm that children with disabilities are more likely to be victims of violence than are their peers who are not disabled. However, the continued scarcity of robust evidence, due to a lack of well designed research studies, poor standards of measurement of disability and violence, and insufficient assessment of whether violence precedes the development of disability, leaves gaps in knowledge that need to be addressed. Funding: WHO Department of Violence and Injury Prevention and Disability.
A systematic review of parent and family-based intervention effectiveness on sexual outcomes in young people
Health Educ Res, 26(5):808-833, 2011.
Abstract: Limited evidence exists about the effectiveness of parent/family-based interventions for preventing poor sexual health outcomes, thus a systematic review was conducted as part of a wider review of community-based sex and relationships and alcohol education. Method guidance from the UK’s National Institute for Health and Clinical Excellence was adhered to. Overall, 18 databases were searched. In total, 12 108 references were identified, of which 440 were retrieved and screened. Overall, 17 studies met the inclusion criteria. Findings showed that parent-based interventions were inconsistently effective at reducing young people’s sexual risk behaviours. Parent-based interventions had greater impact on parent/child communication than family-based interventions, which showed no evidence of effectiveness. However, increasing parent/child communication showed no effect on sexual risk behaviours. Preliminary evidence suggests that effectiveness was greater in those studies aiming to affect multiple risk behaviours. However, this may be due to longer programme delivery and follow-up times; further evidence is required. Sexual health communication was sensitive to intervention. Studies addressing multiple risk behaviours may be as effective as targeted interventions at affecting sexual risk behaviours. Longitudinal controlled studies, examining broader sexual activity outcomes, are needed in countries such as the United Kingdom to inform the evidence base, which is primarily US based, and contribute to related policies and practices.
Journal of Health and Place. 17(2), 508-518, 2011.
Abstract: Drinking environments, including bars, nightclubs and their surrounds are associated with high levels of acute alcohol-related harms. This systematic review examined the effectiveness of interventions implemented in drinking environments to reduce alcohol use and associated harms. The findings of the review were limited by the methodological shortcomings of the included studies. However, three studies indicated that multicomponent programmes combining community mobilisation, RBS training, house policies and stricter enforcement of licensing laws may be effective in reducing assaults, traffic crashes, and underage sales depending on the focus of the intervention. The effectiveness of other intervention approaches was limited. Future studies of interventions in drinking environments should focus on using appropriate and robust study designs.
Environmental factors in drinking venues and alcohol-related harm: the evidence base for European intervention.
Addiction. 106 Supplement 1, 37-46, 2011.
Abstract: Aims: Reducing alcohol-related harm in young people is a major priority across Europe. Much alcohol use and associated harm in young people occurs in public drinking environments. This review aims to identity environmental factors in drinking establishements that are associated with increased alcohol consumption and associated harm and to understand the extent of study in this area across Europe. Methods: A systematic literature search identified studies that had explored associations between physical, staffing and social factors in drinking environments and increased alcohol use or alcohol-related harm. Results: Fifty-three papers were identified, covering 34 studies implemented in nine countries. Most studies had been implemented in non-European countries and many had collected data more than a decade prior to the review. The majority had used observational research techniques. Throughout the studies, a wide range of physical, staffing and social factors had been associated with higher levels of alcohol use and related harm in drinking environments. Factors that appeared particularly important in contributing to alcohol-related problems included a permissive environment, cheap alcohol availability, poor cleanliness, crowding, loud music, a focus on dancing and poor staff practice. However, findings were not always consistent across studies. Conclusions: Drinking establishments, their management and the behaviours of the young people who use them vary widely across Europe. While international research shows that environmental factors in drinking settings can have an important influence on alcohol-related harm, there is currently a scarcity of knowledge on the relevance and impacts of such factors in modern European settings. Developing this knowledge will support the implementation of strategies to create drinking environments in Europe that are less conducive to risky drinking and alcohol-related harm.
Drug Test Analysis, 3(2):89-96, 2011.
Abstract Widespread public perception is that illicit drugs contain substances that are a serious risk to health, even though adulterants are often not considered in clinical or forensic toxicology. This review attempts to present an evidence-based overview of adulterants in illicit drugs, and their associated toxicity. Adulterants are deliberately added to increase bulk, enhance or mimic a pharmacological effect, or to facilitate drug delivery. Those present unintentionally are as a result of poor manufacturing techniques. From the reports gathered, adulterants are predominantly substances which are readily available, commonly being caffeine, procaine, paracetamol, and sugars. These are likely to have minimal impact on users' health at low dosages. Other adulterants, particularly in injectable drugs, have the potential to cause serious health issues, but the quantities reported, such as strychnine in heroin, are not life-threatening. The most commonly identified bacterial contaminants identified are Bacillus and Clostridium species. When death or serious illness due to adulteration occurs, circulation of information is particularly vital, such as in the USA regarding heroin and cocaine adulterated with fentanyl, and in Scotland recently regarding anthrax contaminated heroin. The complex interactions of supply, demand, and control of illicit drugs have a tangible impact on their adulteration. Continuing vigilance and the circulation of information is, therefore, desirable as a public health issue. As part of that strategy, analyses performed for adulterants needs to be encouraged, which are considerably limited in number and scope at the moment.
International Journal of Drug Policy 21 (2010), 335, 2010.
Abstract: The introduction of needle and syringe programmes (NSPs) during the 1980s is credited with averting an HIV epidemic in the United Kingdom and Australia, but hepatitis C (HCV) incidence continues to rise among injecting drug users (IDUs). NSPs incorporating additional harm reduction strategies have been highlighted as an approach that may impact on HCV incidence. This systematic review sought to determine which approaches to the organisation and delivery of NSPs are effective. Fifteen databases were searched for studies published since 1990. Two reviewers screened all titles and abstracts, and data extraction and quality assessment of individual studies were undertaken independently by one reviewer and checked for accuracy by a second. Sixteen studies met the criteria for inclusion. Based on 11 studies there was no evidence of an impact of different NSP settings or syringe dispensation policies on drug injecting behaviours, but mobile van sites and vending machines appeared to attract younger IDUs and IDUs with higher risk profiles. Two studies of interventions aimed at encouraging IDUs to enter drug treatment reported limited effects, but one study found that the combination of methadone treatment and full participation in NSPs was associated with a lower incidence of HIV and HCV. In addition, one study indicated that hospital-based programmes may improve access to health care services among IDUs. Currently, it is difficult to draw conclusions on 'what works best' within the range of harm reduction services available to IDUs. Further studies are required which have a stated aim of evaluating how different approaches to the organisation and delivery NSPs impact on effectiveness.
Teenage drinking, alcohol availability and pricing: a cross-sectional study of risk and protective factors for alcohol-related harms in school children
Professor Mark Bellis, Penelope Phillips-Howard, Professor Karen Hughes, Sara Wood, Penny Cook, , Kerin Hannon, Linda Smallthwaite, Lisa Jones
BMC Public Health. 9, 380, 2009.
Abstract: Background: There is a lack of empirical analyses examining how alcohol consumption patterns in children relate to harms. Such intelligence is required to inform parents, children and policy relating to the provision and use of alcohol during childhood. Here, we examine drinking habits and associated harms in 15-16 year olds and explore how this can inform public health advice on child drinking. Methods: An opportunistic survey of 15-16 year olds (n = 9,833) in North West England was undertaken to determine alcohol consumption patterns, drink types consumed, drinking locations, methods of access and harms encountered. Cost per unit of alcohol was estimated based on a second survey of 29 retail outlets. Associations between demographics, drinking behaviours, alcohol pricing and negative outcomes (public drinking, forgetting things after drinking, violence when drunk and alcohol-related regretted sex) were examined. Results: Proportions of drinkers having experienced violence when drunk (28.8%), alcohol-related regretted sex (12.5%) and forgetting things (45.3%), or reporting drinking in public places (35.8%), increased with drinking frequency, binge frequency and units consumed per week. At similar levels of consumption, experiencing any negative alcohol-related outcome was lower in those whose parents provided alcohol. Drunken violence was disproportionately associated with being male and greater deprivation while regretted sex and forgetting things after drinking were associated with being female. Independent of drinking behaviours, consuming cheaper alcohol was related to experiencing violence when drunk, forgetting things after drinking and drinking in public places. Conclusion: There is no safe level of alcohol consumption for 15-16 year olds. However, while abstinence removes risk of harms from personal alcohol consumption, its promotion may also push children into accessing drink outside family environments and contribute to higher risks of harm. Strategies to reduce alcohol-related harms in children should ensure bingeing is avoided entirely, address the excessively low cost of many alcohol products, and tackle the ease with which it can be accessed, especially outside of supervised environments.