Showing papers in "Public Health Research in 2017"

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Abstract: Background Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years® (IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects. Objectives To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings. Design Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention. Settings UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal. Participants Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys). Interventions IY Basic parenting programme. Main outcome measures Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms. Results There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximum n = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention. Limitations Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention. Conclusions There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions. Funding The National Institute for Health Research Public Health Research programme.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations.

Abstract: Background Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature. Objectives To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems. Design A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work. Results A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations. Limitations Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention. Conclusions Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent. Future work The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public. Study registration The systematic review element of this study is registered as PROSPERO CRD42016026415. Funding The National Institute for Health Research Public Health Research programme.

Increasing boys’ and girls’ intentions to avoid teenage pregnancy: a cluster randomised controlled feasibility trial of an interactive video drama-based intervention in post-primary schools in Northern Ireland

Abstract: Background: Adolescent men have a vital yet neglected role in reducing unintended teenage pregnancy (UTP). There is a need for gender-sensitive educational interventions. Objectives: To determine the value and feasibility of conducting an effectiveness trial of the If I Were Jack Relationship and Sexuality Education (RSE) intervention in a convenience quota sample of post-primary schools in Northern Ireland. Secondary objectives were to assess acceptability to schools, pupils (male/female, aged 14–15 years) and parents/guardians; to identify optimal delivery structures and systems; to establish participation rates and reach, including equality of engagement of different socioeconomic and religious types; to assess trial recruitment and retention rates; to assess variation in normal RSE practice; to refine survey instruments; to assess differences in outcomes for male and female pupils; to identify potential effect sizes that might be detected in an effectiveness trial and estimate appropriate sample size for that trial; and to identify costs of delivery and pilot methods for assessing cost-effectiveness. Design: Cluster randomised Phase II feasibility trial with an embedded process and economic evaluation. Intervention: A teacher-delivered classroom-based RSE resource – an interactive video drama (IVD) with classroom materials, teacher training and an information session for parents – to immerse young people in a hypothetical scenario of Jack, a teenager whose girlfriend is unintentionally pregnant. It addresses gender inequalities in RSE by focusing on young men and is designed to increase intentions to avoid UTP by encouraging young people to delay sexual intercourse and to use contraception consistently in sexual relationships. Main outcome measures: Abstinence from sexual intercourse (delaying initiation of sex or returning to abstinence) or avoidance of unprotected sexual intercourse (consistent correct use of contraception). Secondary outcomes included Knowledge, Attitudes, Skills and Intentions. Results: The intervention proved acceptable to schools, pupils and parents, as evidenced through positive process evaluation. One minor refinement to the parental component was required, namely the replacement of the teacher-led face-to-face information session for parents by online videos designed to deliver the intervention to parents/guardians into their home. School recruitment was successful (target 25%, achieved 38%). No school dropped out. Pupil retention was successful (target 85%, achieved 93%). The between-group difference in incidence of unprotected sex of 1.3% (95% confidence interval 0.55% to 2.2%) by 9 months demonstrated an effect size consistent with those reported to have had meaningful impact on UTP rates (resulting in an achievable sample size of 66 schools at Phase III). Survey instruments showed high acceptability and reliability of measures (Cronbach’s alpha: 0.5–0.7). Economic evaluation at Phase III is feasible because it was possible to (1) identify costs of delivering If I Were Jack (mean cost per pupil, including training of teachers, was calculated as £13.66); and (2) develop a framework for assessing cost-effectiveness. Conclusion: Trial methods were appropriate, and recruitment and retention of schools and pupils was satisfactory, successfully demonstrating all criteria for progression to a main trial. The perceived value of culture- and gender-sensitive public health interventions has been highlighted. Future work: Progression to a Phase III effectiveness trial. Trial registration: Current Controlled Trials ISRCTN99459996. Funding: This project was funded by the NIHR Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 1. See the NIHR Journals Library website for further project information.

Assessing the impact and cost-effectiveness of needle and syringe provision and opioid substitution therapy on hepatitis C transmission among people who inject drugs in the UK: an analysis of pooled data sets and economic modelling

Abstract: Background There is limited evidence of the impact of needle and syringe programmes (NSPs) and opioid substitution therapy (OST) on hepatitis C virus (HCV) incidence among people who inject drugs (PWID), nor have there been any economic evaluations. Objective(s) To measure (1) the impact of NSP and OST, (2) changes in the extent of provision of both interventions, and (3) costs and cost-effectiveness of NSPs on HCV infection transmission. Design We conducted (1) a systematic review; (2) an analysis of existing data sets, including collating costs of NSPs; and (3) a dynamic deterministic model to estimate the impact of differing OST/NSP intervention coverage levels for reducing HCV infection prevalence, incidence and disease burden, and incremental cost-effectiveness ratios to measure the cost-effectiveness of current NSP provision versus no provision. Setting Cost-effectiveness analysis and impact modelling in three UK sites. The pooled analysis drew on data from the UK and Australia. The review was international. Participants PWID. Interventions NSP coverage (proportion of injections covered by clean needles) and OST. Outcome New cases of HCV infection. Results The review suggested that OST reduced the risk of HCV infection acquisition by 50% [rate ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63]. Weaker evidence was found in areas of high (≥ 100%) NSP coverage (RR 0.77, 95% CI 0.38 to 1.54) internationally. There was moderate evidence for combined high coverage of NSPs and OST (RR 0.29, 95% CI 0.13 to 0.65). The pooled analysis showed that combined high coverage of NSPs and OST reduced the risk of HCV infection acquisition by 29–71% compared with those on minimal harm reduction (no OST, ≤ 100% NSP coverage). NSPs are likely to be cost-effective and are cost-saving in some settings. The impact modelling suggest that removing OST (current coverage 81%) and NSPs (coverage 54%) in one site would increase HCV infection incidence by 329% [95% credible interval (CrI) 110% to 953%] in 2031 and at least double (132% increase; 95% CrI 51% to 306%) the number of new infections over 15 years. Increasing NSP coverage to 80% has the largest impact in the site with the lowest current NSP coverage (35%), resulting in a 27% (95% CrI 7% to 43%) decrease in new infections and 41% (95% CrI 11% to 72%) decrease in incidence by 2031 compared with 2016. Addressing homelessness and reducing the harm associated with the injection of crack cocaine could avert approximately 60% of HCV infections over the next 15 years. Limitations Findings are limited by the misclassification of NSP coverage and the simplified intervention definition that fails to capture the integrated services that address other social and health needs as part of this. Conclusions There is moderate evidence of the effectiveness of OST and NSPs, especially in combination, on HCV infection acquisition risk. Policies to ensure that NSPs can be accessed alongside OST are needed. NSPs are cost-saving in some sites and cost-effective in others. NSPs and OST are likely to prevent considerable rates of HCV infection in the UK. Increasing NSP coverage will have most impact in settings with low coverage. Scaling up other interventions such as HCV infection treatment are needed to decrease epidemics to low levels in higher prevalence settings. Future work To understand the mechanisms through which NSPs and OST achieve their effect and the optimum contexts to support implementation. Funding The National Institute for Health Research Public Health Research programme.

Steps Towards Alcohol Misuse Prevention Programme (STAMPP): a school- and community-based cluster randomised controlled trial

Abstract: Background Alcohol use in young people remains a public health concern, with adverse impacts on outcomes such as health, well-being, education and relationships. Objectives To assess the effectiveness and cost-effectiveness of a combined classroom curriculum and parental intervention on self-reported alcohol use [heavy episodic drinking (HED)] and alcohol-related harms (indicators such as getting into fights after drinking, poorer school performance and trouble with friends and family). Design A two-arm, cluster randomised controlled trial with schools as the unit of randomisation. Setting A total of 105 post-primary schools in Northern Ireland (NI) and Glasgow/Inverclyde Educational Authority areas. Participants A total of 12,738 male and female secondary school students (intervention delivered when students were in school year 9 in NI or S2 in Scotland in the academic year 2012–13 and aged 12–13 years) were randomised. Randomisation and baseline (T0) surveys took place when children were in school year 8 or S1. Schools were randomised (1 : 1) by an independent statistician to the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) or to education as normal (EAN). All schools were stratified by free school meal provision. Schools in NI were also stratified by school type (male/female/coeducational). Interventions STAMPP combined a school-based alcohol harm reduction curriculum [an adapted version of the School Health and Alcohol Harm Reduction Project (SHAHRP)] and a brief parental intervention designed to support parents in setting family rules around drinking. The classroom component comprised two phases delivered over 2 years, and the parental component comprised a standardised presentation delivered by a trained facilitator at specially arranged parent evenings on school premises. This was followed up a few weeks later by an information leaflet mailed to all intervention pupils’ parents highlighting the main points of the evening. Main outcome measures (1) Self-reported HED (defined as self-reported consumption of ≥ 6 units in a single episode in the previous 30 days for male students and ≥ 4.5 units for female students) assessed at 33 months from baseline (T3); and (2) the number of self-reported harms (harms caused by own drinking) assessed at T3. Data sources Self-completed pupil questionnaires. Results At final follow-up (T3), data were available for 5160 intervention and 5073 control pupils for the HED outcome, and for 5234 intervention and 5146 control pupils for the self-reported harms outcome. The intervention reduced self-reported HED compared with EAN (p < 0.001), but did not reduce self-reported harms associated with own drinking. The odds ratio for the intervention effect on HED was 0.596 (standard error 0.0596, 95% confidence interval 0.490 to 0.725). The mean cost of delivery per school was £818 and the mean cost per individual was £15. There were no clear cost savings in terms of service utilisation associated with the intervention. The process evaluation showed that the classroom component engaged and was enjoyed by pupils, and was valued by teachers. Schools, students, intervention trainers and delivery staff (teachers) were not blind to study condition. Data collection was undertaken by a team of researchers that included the trial manager and research assistants, some of whom were not blinded to study condition. Data analysis of primary and secondary outcomes was undertaken by the trial statistician, who was blinded to the study condition. Limitations Although the classroom component was largely delivered as intended, there was very low attendance at the parent/carer event; however, all intervention pupils’ parents/carers received an intervention leaflet. Conclusions The results of this trial provide some support for the effectiveness and cost-effectiveness of STAMPP in reducing heavy episodic (binge) drinking, but not in reducing self-reported alcohol-related harms, in young people over a 33-month follow-up period. As there was low uptake of the parental component, it is uncertain whether or not the intervention effect was accounted for by the classroom component alone. Trial registration Current Controlled Trials ISRCTN47028486. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 2. See the NIHR Journals Library website for further project information. The Public Health Agency of NI and Education Boards of Glasgow/Inverclyde provided some intervention costs. Diageo provided funds to print some workbooks. The remaining intervention costs were internally funded.

Adapting the ASSIST model of informal peer-led intervention delivery to the Talk to FRANK drug prevention programme in UK secondary schools (ASSIST + FRANK): intervention development, refinement and a pilot cluster randomised controlled trial

Abstract: Background: Illicit drug use increases the risk of poor physical and mental health. There are few effective drug prevention interventions. Objective: To assess the acceptability of implementing and trialling two school-based peer-led drug prevention interventions. Design: Stage 1 – adapt ASSIST, an effective peer-led smoking prevention intervention to deliver information from the UK national drug education website [see www.talktofrank.com (accessed 29 August 2017)]. Stage 2 – deliver the two interventions, ASSIST + FRANK (+FRANK) and FRANK friends, examine implementation and refine content. Stage 3 – four-arm pilot cluster randomised control trial (cRCT) of +FRANK, FRANK friends, ASSIST and usual practice, including a process evaluation and an economic assessment. Setting: Fourteen secondary schools (two in stage 2) in South Wales, UK. Participants: UK Year 8 students aged 12–13 years at baseline. Interventions: +FRANK is a UK informal peer-led smoking prevention intervention provided in Year 8 followed by a drug prevention adjunct provided in Year 9. FRANK friends is a standalone informal peer-led drug prevention intervention provided in Year 9. These interventions are designed to prevent illicit drug use through training influential students to disseminate information on the risks associated with drugs and minimising harms using content from www.talktofrank.com. Training is provided off site and follow-up visits are made in school. Outcomes: Stage 1 – +FRANK and FRANK friends intervention manuals and resources. Stage 2 – information on the acceptability and fidelity of delivery of the interventions for refining manuals and resources. Stage 3 – (a) acceptability of the interventions according to prespecified criteria; (b) qualitative data from students, staff, parents and intervention teams on implementation and receipt of the interventions; (c) comparison of the interventions; and (d) recruitment and retention rates, completeness of primary, secondary and intermediate outcome measures and estimation of costs. Results: +FRANK and FRANK friends were developed with stakeholders [young people, teachers (school management team and other roles), parents, ASSIST trainers, drug agency staff and a public health commissioner] over an 18-month period. In the stage 2 delivery of +FRANK, 12 out of the 14 peer supporters attended the in-person follow-ups but only one completed the electronic follow-ups. In the pilot cRCT, 12 schools were recruited, randomised and retained. The student response rate at the 18-month follow-up was 93% (1460/1567 students). Over 80% of peer supporters invited were trained and reported conversations on drug use and contact with trainers. +FRANK was perceived less positively than FRANK friends. The prevalence of lifetime illicit drug use was 4.1% at baseline and 11.6% at follow-up, with low numbers of missing data for all outcomes. The estimated cost per school was £1942 for +FRANK and £3041 for FRANK friends. All progression criteria were met. Conclusions: Both interventions were acceptable to students, teachers and parents, but FRANK friends was preferred to +FRANK. A limitation of the study was that qualitative data were collected on a self-selecting sample. Future work recommendations include progression to a Phase III effectiveness trial of FRANK friends. Trial registration: Current Controlled Trials ISRCTN14415936. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 7. See the NIHR Journals Library website for further project information. The work was undertaken with the support of the Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer). Joint funding (MR/KO232331/1) from the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Medical Research Council, the Welsh Government and the Wellcome Trust, under the auspices of the UK CRC, is gratefully acknowledged.

Evaluation of Health in Pregnancy grants in Scotland: a natural experiment using routine data

Abstract: Background Pregnancy and the period around birth are critical for the development and improvement of population health as well as the health of mothers and babies, with outcomes such as birthweight influencing adult health. Objectives We evaluated the clinical effectiveness and cost-effectiveness of the Health in Pregnancy (HiP) grants in Scotland, looking for differential outcomes when the scheme was in place, as well as before its implementation and after its withdrawal. Design The HiP grants were evaluated as a natural experiment using interrupted time series analysis. We had comparison groups of women who delivered before the grants were introduced and after the grants were withdrawn. Setting Scotland, UK. Participants A total of 525,400 singleton births delivered between 24 and 44 weeks in hospitals across Scotland between 1 January 2004 and 31 December 2014. Intervention The HiP grant was a universal, unconditional cash transfer of £190 for women in Great Britain and Northern Ireland reaching 25 weeks of pregnancy if they had sought health advice from a doctor or midwife. The grant was introduced for women with a due date on or after 6 April 2009 and subsequently withdrawn for women reaching the 25th week of pregnancy on or after 1 January 2011. The programme was paid for by Her Majesty’s Treasury. Main outcome measures Our primary outcome measure was birthweight. Secondary outcome measures included maternal behaviour, measures of size, measures of stage and birth outcomes. Data sources The data came from the Scottish maternity and neonatal database held by the Information and Services Division at the NHS National Services Scotland. Results There was no statistically significant effect on birthweight, with births during the intervention period being, on average, 2.3 g [95% confidence interval (CI) –1.9 to 6.6 g] lighter than would have been expected had the pre-intervention trend continued. Mean gestational age at booking (i.e. the first antenatal appointment with a health-care professional) decreased by 0.35 weeks (95% CI 0.29 to 0.41 weeks) and the odds of booking before 25 weeks increased by 10% [odds ratio (OR) 1.10, 95% CI 1.02 to 1.18] during the intervention but decreased again post intervention (OR 0.91, 95% CI 0.83 to 1.00). The odds of neonatal death increased by 84% (OR 1.84, 95% CI 1.22 to 2.78) and the odds of having an emergency caesarean section increased by 7% (OR 1.07, 95% CI 1.03 to 1.10) during the intervention period. Conclusions The decrease in the odds of booking before 25 weeks following withdrawal of the intervention makes it likely that the HiP grants influenced maternal health-care-seeking behaviour. It is unclear why neonatal mortality and emergency caesarean section rates increased, but plausible explanations include the effects of the swine flu outbreak in 2009 and the global financial crisis. The study is limited by its non-randomised design. Future research could assess an eligibility threshold for payment earlier than the 25th week of pregnancy. Funding The National Institute for Health Research Public Health Research programme. The Social and Public Health Sciences Unit is core funded by the Medical Research Council (MC_UU_12017/13) and the Scottish Government Chief Scientist Office (SPHSU13).

Health impacts of the M74 urban motorway extension: a mixed-method natural experimental study

Abstract: Background Making travel easier can improve people’s access to opportunities, but motor transport also incurs substantial undesirable health and social impacts. Aims To assess how a new urban motorway affected travel and activity patterns, road accidents and well-being in local communities, and how these impacts were experienced and brought about. Design The Traffic and Health in Glasgow study, a mixed-method controlled before-and-after study. Setting Glasgow, UK. Participants Repeat cross-sectional survey samples of 1345 and 1343 adults, recruited in 2005 and 2013, respectively. Of these, 365 formed a longitudinal cohort, 196 took part in a quantitative substudy using accelerometers and global positioning system receivers and 30, living within 400 m of the new motorway, took part in a qualitative substudy along with 12 other informants. Complementary analyses used police STATS19 road traffic accident data (1997–2014) and Scottish Household Survey travel diaries (2009–13). Intervention A new 5-mile, six-lane section of the M74 motorway, opened in 2011 and running through predominantly deprived neighbourhoods in south-east Glasgow, with associated changes to the urban landscape. Main outcome measures Differences in self-reported travel behaviour (1-day travel record), physical activity (short International Physical Activity Questionnaire) and well-being [Short Form 8 Health Survey (SF-8) and a short version of the Warwick–Edinburgh Mental Well-being Scale], and in the incidence of road traffic accidents. Methods A combination of multivariable cohort, cross-sectional, repeat cross-sectional and interrupted time series regression analyses comparing residents of the ‘M74 corridor’ intervention area and two matched control areas, complemented by novel qualitative spatial methods. Graded measures of the proximity of the motorway to each participant’s home served as a further basis for controlled comparisons. Results Both benefits and harms were identified. Cohort participants living closer to the new motorway experienced significantly reduced mental well-being (mental component summary of the SF-8 scale) over time compared with those living further away [linear regression coefficient –3.6, 95% confidence interval (CI) –6.6 to –0.7]. In the area surrounding an existing motorway, this association was concentrated among those with chronic conditions. In repeat cross-sectional analyses, participants living closer to a new motorway junction were more likely to report using a car at follow-up than those living further away (odds ratio 3.4, 95% CI 1.1 to 10.7). We found weaker quantitative evidence of a decline in physical activity participation and no quantitative evidence of an overall change in either active travel or accidents associated with motorway exposure. Qualitative evidence suggested that, although the new motorway improved connectivity for those with dispersed social networks and access to motor vehicles, the impacts were more complex for others, some of whom found the motorway to be a cause of severance. Changes in community composition and cohesion, and perceptions of personal safety, were widely perceived as more important to local people. Limitations A key limitation of natural experimental studies is that the risk of residual confounding cannot be eliminated. Conclusions Overall, these findings highlight the potential for urban infrastructural projects of this kind to add further burdens to already disadvantaged communities, exacerbating inequalities and contributing to poorer health outcomes. The health and social impacts of such initiatives should be more fully taken into account in planning and research. Funding The National Institute for Health Research Public Health Research programme.

Assessing Ecosystem Liabilities of Oil and Gas Activities in Southern Nigeria

Abstract: Since the discovery of oil in the Niger Delta region, the sector’s contribution to Nigeria’s economy came at a huge environmental cost involving recurrent spills resulting in the spewing of oil into sensitive ecosystems. In the process, gas flaring from the industry has accelerated at an alarming rate and degrading the fragile mangrove ecosystem. The problems are characterized by widespread pollution of water resources and threats to the surrounding ecology in the form of deforestation, loss of habitats, and damage to biodiversity. Yet very little has been done to fully assess the impacts on the Delta region. In that light, this research uses mix-scale methods of GIS and descriptive statistics to assess the environmental liabilities of petroleum activities in Southern Nigeria from 1963-2013. Emphasis is on the issues, ecological analysis of the impacts, factors and spatial analysis. While the results point to changes in production and ecosystem degradation prompted by the concentration of greenhouse gases, rise in CO2 emissions, widespread incidents of gas flaring and oil spills. GIS mappings show a gradual dispersion of various liabilities such as fire outbreaks at facilities all through 2002-2003 along with visible presence of gas flaring in the 2000s followed by a robust spread of oil spills across various states in the Delta between the periods of the 1980s-1990s and a reemergence in the 2000s. The spatial cluster of supply infrastructure stayed intact while oil shipments to different zones in Nigeria fluctuated in the South with slight increases in the North from 2007-2013. With the ecological liabilities linked to socio-economic factors of ineffective guidelines, local demands and oil exports, the paper proffered suggestions ranging from the strengthening of policy to continued impact assessment.

Results of the First Steps study: a randomised controlled trial and economic evaluation of the Group Family Nurse Partnership (gFNP) programme compared with usual care in improving outcomes for high-risk mothers and their children and preventing abuse

Abstract: Background Family Nurse Partnership (FNP) is a home-based nurse home-visiting programme to support vulnerable parents. Group Family Nurse Partnership (gFNP) has similar aims and materials and was demonstrated to be feasible in implementation evaluations. Objectives To determine whether or not gFNP, compared with usual care, could reduce risk factors for maltreatment in a vulnerable group and be cost-effective. Design A multisite randomised controlled parallel-group trial and prospective economic evaluation, with eligible women allocated (minimised by site and maternal age group) to gFNP or usual care. Setting Community locations in the UK. Participants Expectant mothers aged Intervention Forty-four sessions of gFNP (14 during pregnancy and 30 in the first 12 months after birth) were offered to groups of between 8 and 12 women with similar expected delivery dates (the difference between the earliest and latest expected delivery date ranged from 8 to 10 weeks depending on the group) by two family nurses (FNs), one of whom had notified her intention to practise as a midwife. Main outcome measures Parenting was assessed by a self-report measure of parenting opinions, the Adult Adolescent Parenting Inventory Version 2 (AAPI-2), and an objective measure of maternal sensitivity, the CARE-Index. Cost-effectiveness was primarily expressed in terms of incremental cost per quality-adjusted life-year (QALY) gained. Data sources Interviews with participants at baseline and when infants were aged 2, 6 and 12 months. Cost information from nurse weekly logs and other service delivery data. Results In total, 166 women were enrolled (99 to the intervention group and 67 to the control group). Adjusting for site and maternal age group, the intention-to-treat analysis found no effect of gFNP on either of the primary outcomes. AAPI-2 total was 7.5/10 [standard error (SE) 0.1] in both arms [difference also adjusted for baseline 0.08, 95% confidence interval (CI) –0.15 to 0.28; p = 0.50]. CARE-Index maternal sensitivity mean: intervention 4.0 (SE 0.3); control 4.7 (SE 0.4) (difference –0.76, 95% CI –1.67 to 0.13; p = 0.21). The sensitivity analyses supported the primary analyses. The probability that the gFNP intervention was cost-effective based on the QALY measure did not exceed 3%. However, in terms of change in AAPI-2 score (baseline to 12 months), the probability that gFNP was cost-effective reached 25.1%. A separate discrete choice experiment highlighted the value placed by both pregnant women and members of the general population on non-health outcomes that were not included in the QALY metric. Limitations Slow recruitment resulted in smaller than ideal group sizes. In some cases, few or no sessions took place owing to low initial group size, and small groups may have contributed to attrition from the intervention. Exposure to gFNP sessions was below maximum for most group members, with only 58 of the 97 intervention participants receiving any sessions; FNs were experienced with FNP but were mainly new to delivering gFNP. Conclusions The trial does not support the delivery of gFNP as a means of reducing the risk of child abuse or neglect in this population. Future work A randomised controlled trial with modified eligibility to enable first-time mothers aged Trial registration Current Controlled Trials ISRCTN78814904. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research ; Vol. 5, No. 9. See the NIHR Journals Library website for further project information.

Prevalence and Antibiotic Susceptibility of Listeria monocytogenes in Retailed Meats in Port Harcourt Metropolis, Nigeria

Abstract: Listeria monocytogenes is the causative agent of Listeriosis, a disease of humans and animals owing to food and environmental contamination as well as zoonotic infections. Globally, this has become an emerging and zoonotic bacterial disease having low incidence with however high case fatality rate. The essence of this study was to isolate L. monocytogenes from retail beef and pork samples purchased from five markets within Port-Harcourt metropolis and to detect their antimicrobial profile. One hundred samples of retail beef and pork were purchased from different vendors across the five markets using cross-sectional study design from November 2013 to March 2014. The samples were examined for the occurrence of Listeria monocytogenes and other Listeria species using standard microbiological methods. From the study, of 100 samples (50 each for beef and pork) analyzed, 19(19.0%) confirmed the presence of Listeria species. Of these nineteen isolates, 7(36.8%) were Listeria monocytogenes while 12(63.2%) were other Listeria species [L. Ivanovic 2(10.5%), L. innocuous 7(36.8%), L. grayi 2(10.5%), and L. seeligeri 1(5.3%)] of the total samples. Although there was insignificant difference (p>0.05) in the contamination levels of beef and pork meat, there was however a substantial variation (p<0.05) in the contamination level of the different locations with Trans-Amadi and Creek road markets having the highest incidence of 7/19(36.8%) each, Mile-1 Market did not have any positive sample for Listeria. The antibiotics profile of the Listeria monocytogenes strains was done by using the standard disc diffusion method (Muller Hinton Agar) against 14 antibiotics. All isolates were (100.0%) susceptible to Chloramphenicol, Gentamicin, Ampiclox, Clotrimoxazole and Streptomycin. It also showed that they were all (100.0%) resistant to Augmentin, Erythromycin, Tetracycline, Rifampicin, and Cloxacillin. The isolates also showed varying degree of resistance to Norfloxacin (4 resistant, 57.2%), Levofloxacin (5 resistant, 71.4%), and Ciprofloxacin (5 resistant, 71.4%). This study further confirms the presence of Listeria monocytogenes and other Listeria species in beef and pork meat samples in Port Harcourt metropolis, Nigeria which is a cause for public health concerns because of the danger this poses especially through cross-contamination and inadequate cooking of meat products. There is a need for relevant public health agencies in Nigeria to create awareness to vendors and consumers about Listeria in food and its potential as a food pathogen of interest.

The Nexus between Khat and Other Drug use among Undergraduate Students of Jigjiga University in Ethiopia; Contributing Factors and Prevalence Rates

Abstract: Use of substances such as alcohol, khat leaves (Catha edulis) and tobacco has become one of the rising major public health and socio-economic problems worldwide. The issue of substance use among University students, in Ethiopia, has been given less attention and related to different factors. The objective of this research was to assess the Substance use among undergraduate students of Jigjiga University in Ethiopia: The study was conducted in Jigjiga University which is the only University in Somali region. Cross sectional study design was used and the study population was students from selected departments and the sample size was calculated by use of single population proportion formula, accordingly the calculated sample size was 648 after multiplying by design effect of 1.5 and 10 contingency. Data was collected by use of structured questionnaire and first checked manually for completeness and then entered into Epi-data version 3.1. After data coding, entry and cleaning, the data was exported to SPSS version 16.0 for analysis. Descriptive statistics, binary and multiple logistic regressions was employed. Adjusted Odds ratios together with corresponding 95% confidence intervals was used to interpret the findings. From the total 600 respondents 52.5% of them responded yes to the use of khat and one of the other substances. Accordingly ever use was 33.3%, 14.5%, and 14.7% for khat, cigarette, and other drugs respectively. The odds of drinking alcohol was higher among senior students; those at 3rd year with AOR=5(95% CI=2.13, 10.25), those at 4th year with AOR=4.92(95% CI=1.98, 12.14), compared with their junior 2nd year students. Male sex and use of another substance were positively associated to the use of the other substance.

Pilot trial and process evaluation of a multilevel smoking prevention intervention in further education settings

Abstract: Background Preventing smoking uptake among young people is a public health priority. Further education (FE) settings provide access to the majority of 16- to 18-year-olds, but few evaluations of smoking prevention interventions have been reported in this context to date. Objectives To evaluate the feasibility and acceptability of implementing and trialling a new multilevel smoking prevention intervention in FE settings. Design Pilot cluster randomised controlled trial and process evaluation. Setting Six UK FE institutions. Participants FE students aged 16–18 years. Intervention ‘The Filter FE’ intervention. Staff working on Action on Smoking and Health Wales’ ‘The Filter’ youth project applied existing staff training, social media and youth work resources in three intervention settings, compared with three control sites with usual practice. The intervention aimed to prevent smoking uptake by restricting the sale of tobacco to under-18s in local shops, implementing tobacco-free campus policies, training FE staff to deliver smoke-free messages, publicising The Filter youth project’s online advice and support services, and providing educational youth work activities. Main outcome measures (1) The primary outcome assessed was the feasibility and acceptability of delivering and trialling the intervention. (2) Qualitative process data were analysed to explore student, staff and intervention team experiences of implementing and trialling the intervention. (3) Primary, secondary and intermediate (process) outcomes and economic evaluation methods were piloted. Data sources New students at participating FE settings were surveyed in September 2014 and followed up in September 2015. Qualitative process data were collected via interviews with FE college managers (n = 5) and the intervention team (n = 6); focus groups with students (n = 11) and staff (n = 5); and observations of intervention settings. Other data sources were semistructured observations of intervention delivery, intervention team records, ‘mystery shopper’ audits of local shops and college policy documents. Results The intervention was not delivered as planned at any of the three intervention settings, with no implementation of some community- and college-level components, and low fidelity of the social media component across sites. Staff training reached 28 staff and youth work activities were attended by 190 students across the three sites (< 10% of all eligible staff and students), with low levels of acceptability reported. Implementation was limited by various factors, such as uncertainty about the value of smoking prevention activities in FE colleges, intervention management weaknesses and high turnover of intervention staff. It was feasible to recruit, randomise and retain FE settings. Prevalence of weekly smoking at baseline was 20.6% and was 17.2% at follow-up, with low levels of missing data for all pilot outcomes. Limitations Only 17% of eligible students participated in baseline and follow-up surveys; the representativeness of student and staff focus groups is uncertain. Conclusions In this study, FE settings were not a supportive environment for smoking prevention activities because of their non-interventionist institutional cultures promoting personal responsibility. Weaknesses in intervention management and staff turnover also limited implementation. Managers accept randomisation but methodological work is required to improve student recruitment and retention rates if trials are to be conducted in FE settings. Trial registration Current Controlled Trials ISRCTN19563136. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information. It was also funded by the Big Lottery Fund.

Comparison of Practising and Student Teachers’ Knowledge of Cardiopulmonary Resuscitation in Nigeria

Abstract: Background /Objective of the Study: School teachers are expected to be involved in the training of school children in cardiopulmonary resuscitation (CPR), as well serve as bystander CPR providers in out-of-hospital cardiac arrest (OHCA) victims both in school environment and the larger communities. Meanwhile, Nigerian teachers are not prepared for these functions. Therefore, this study aimed at comparing the pre-training and post-training CPR knowledge of some Nigerian practising teachers and student teachers (potential teachers). Materials and Methods: A quasi-experimental study design involving two cohorts of 41 participants each (practising and student teachers) - 9 (21.95%) male and 36(78.05%) female in each group with age ranges of 20-50 years for practising teachers and 18-28 years for the student teachers was carried out. Using the American Heart Association protocol, each group at different times answered some questions on CPR knowledge using a self-administered questionnaire before and after CPR trainings. The data were analysed using descriptive statistics and the null hypotheses tested using paired T-tests with significance value set at P .05), but the student teachers’ post-training CPR knowledge was found to be statistically significantly better than that of the practising teachers (P <.001). Conclusion: Although both cohorts had pre-training ‘poor CPR knowledge’, the student teachers showed significantly better improvement in CPR knowledge after the training, showing that they were better in understanding the subject.

Awareness and Factors that Influence Birth Preparedness and Complication Readiness among Pregnant Women Attending Antenatal Clinic in the General Hospital Calabar, Nigeria

Abstract: Every pregnant woman is at risk of developing complications during the period of pregnancy and immediate post delivery period. Proper birth plan/preparation and ability to recognize danger signs can help reduce the various phases of delays and ensure prompt and quality care when needed. However, various studies have shown that the knowledge and level of birth plan and complication readiness (BP/CR) among pregnant women is low. Hence this study was embarked upon to determine the impact of Focused Antenatal Care (FANC) with regard to BP/CR and suggest possible ways of improving maternal care. A questionnaire based cross-sectional descriptive study was conducted among 230 pregnant women receiving ante natal care in the General Hospital Calabar. Simple random sampling method was used to select participants. The response rate was 94.33% (217). Effective BP/CR was recorded in 33.1% of the respondents. Level of education (p<0.05, x2=33.4), partner’s support, and previous bad obstetric experiences (p=0.003) were positively associated with effective BP/CR. Lack of awareness was a major reason for poor BP/CR. There is need for male/partners involvement in care of pregnancy and antenatal education should lay more emphasis on the issue of BP/CR.

Risk Factors of Hyperbilirubinemia among Admitted Neonates in the Gaza Strip: Case Control Study

Abstract: Neonatal hyperbilirubinemia is a widespread and significant clinical condition among neonates worldwide. This study aims at identifying the main risk factors, either socio-demographic, maternal or neonatal, that contribute to neonatal hyperbilirubinemia among hospitalized neonates in the Gaza Strip. The study is designed in a case-control fashion. The sample consists of 180 neonates (90 cases and 90 controls). Cases were selected from Al- Nasser pediatric hospital and Naser Medical Complex, while controls were selected from Khanyou ILS Martyrs clinic and Al-Remal Martyrs clinic. The researcher used an interview-structured questionnaire in the data collection process.Study results reveal that there is a significant association between family income and neonatal hyperbilirubinemia (P value 2300 ILS (reference group), maternal anemia groups; yes (AOR: 5.383, 95% CI: 1.035-27.998) and no (reference group), and birth weight groups; 2500 – 3000grams (AOR: 0.117, 95% CI: 0.028-0.498) and > 3000grams (reference group). All feeding practices shared a statistically significant association with hyperbilirubinemia occurrence, except the number of wet diapers/24hours as follows: feeding method groups; exclusive (AOR: 0.017, 95% CI: 0.003-0.093), bottle (AOR: 0.006, 95% CI: 0.000-0.141), and mixed (reference group), feeding initiation time groups; 1st hour (reference group) and more than 4 hours (AOR: 0.046, 95% CI: 0.004-0.586), feeding difficulty groups; yes (AOR: 0.079, 95% CI: 0.019-0.328), and no(reference group), lastly feeding frequency groups; on demand (reference group), every 2-3 hours (AOR: 0.108, 95% CI: 0.026-0.448)], and more than 3 hours (AOR: 0.003, 95% CI: 0.000-0.045). In conclusion, the study recommends the need for paying attention to ongoing screening and close monitoring ofat-high-risk neonates. In addition, emphasis should be directed at Health Education regarding effective feeding practices to reduce the rates of hospital readmissions and morbidities of neonatal hyperbilirubinemia.

Epidemiology of Cigarette Smoking among Adolescent Male Students in Qassim, Saudi Arabia

Abstract: Background: Although there are many published data on adolescents’ cigarette smoking, few published data exist on epidemiology of smoking in Kingdom Saudi Arabia (KSA) especially Qassim region. The aim of this study was to determine the epidemiology of adolescent cigarette smoking in Qassim region. Methods: A school-based cross-sectional study was carried out in Qassim region. A multistage stratified cluster sample was conducted. Socio-demographic and smoking-related factors were gathered using questionnaire. Results: Of 710, 680 (95.7%) students responded. Out of these 680, 161 students (23.6%) were smokers. Around one third (56, 34.7%) of the students started smoking at 13 years of age. The place of their friend (Istraha) (40.0, 24.9%), public places (38.0, 23.6%), at home (37, 22.9%) were the places of smoking among these students. In binary logistic regression, while there was no significant association between the tested variables and smoking; students who had smoking friends were 2.3 times more likely to smoke (OR=2.35, 95% CI=1.49−3.70, P < 0.001). Conclusion: This study showed that the prevalence of smoking among adolescent boys is substantial, they initiate smoking at a young age, and it is reinforced by their peers. Future studies showed focus on culture-specific methods to prevent smoking initiation.

The Role of Mobile Health in Supporting Cancer Prevention, Detection, Treatment and Palliative Care in Low and Middle Income Countries: A Scoping Review

Abstract: Cancer is one of the non-communicable diseases with high morbidity and mortality rates, particularly in low-and-middle income countries. Increasing cancer burden is attributable to lifestyle risk factors, poor health system infrastructures, rapid population growth and ageing. These challenges are predicted to persist for years to come; thus the cancer burden is feared to become a major public health crisis hence need for innovative approaches to manage it. Though the widespread use of mobile health technologies in low and middle income countries can potentially address these challenges, evidence on mobile health use has not been fully explored. This study aim to examine the existing published and unpublished literature on the use of mobile technology-based interventions designed to support cancer prevention, detection, treatment and palliation in LMICs. The study adapted a scoping review approach using Arksey & O’Malley (2005) methodological framework. Six electronic databases; Medline, EMBASE, PsycINFO, PubMed, Web of Science and WHO Global Health Library were systematically searched for relevant studies between 1990 to 2014. The search also included additional sources from trial registers, Google, Google Scholar and reference lists. The search yielded 523 articles of which 16 were reviewed, one of these being an ongoing trial. The key findings revealed that mHealth technologies had significantly contributed to the positive outcomes in the cancer care in various contexts with all mobile technology-based features used showing improvement in care delivery. The cell phones were the common mobile device used (46.6% of the studies) followed by Smartphone (26.6%), while SMS was a commonly used mHealth feature. Mobile health interventions predominantly targeted cancer screening and diagnosis in the continuum of care, with less focus on treatment and palliation support. In conclusion, mobile health interventions have a high potential to transform cancer services in low resource settings.However, there is a paucity of evidence on mobile health interventions for cancer care. Most of the reviewed studies were descriptive, hence the need for robust studies with multidimensional focus, including control of risk factors, treatment compliance and palliative care.

To Assess the Tuberculosis Situation in Urban and Rural Areas of Bangladesh with Special Emphasis on the Facility of Treatment Scenarios

Abstract: Background: Tuberculosis (TB) is one of the major public health challenges in Bangladesh. Though the country has achieved commendable success in Tuberculosis control, yet this success may deem out unless effective TB treatment control measures are taken based on strong general infection control for the diseases over the country. This study aimed to assess facilitators for health seeking practice among the urban and rural peoples Bangladesh. Methods: Present study used secondary data extracted from nationally representative Bangladesh Demographic and Health Survey (BDHS-2011) between May 2, 2014 & August 14, 2014, on TB patients receiving TB treatments in Urban and Rural areas from Seven Divisions of Bangladesh. Results: Out of 1596 study subjects, 226 TB patients took TB treatment of which Most of the TB patients were from urban (143, 63.3%), others from Rural (83, 36.7%) areas. Availability of treatment for TB from government/public health authorities are known to 116(51.3%) and 82(36.3%) from urban and rural areas respectively. Our study reflects most of the Tuberculosis medicine facility stored in respective urban service site (122, 54%) where else no Tuberculosis medicine facility in rural areas is 21(9.3%). The study has found that, most long term treatment facility has been provided in urban areas compared to rural areas and no association was found between methods to diagnose TB between urban/rural areas. Conclusions: Perceptions of TB and awareness associated with the disease increase the treatment scenarios, therefore promotion of media awareness campaign, engaging the rural people for treatment and effective community service all over the country is needed to increase treatment facility in the future.

Perceived Risk, Willingness for Vaccination and Uptake of Hepatitis B Vaccine among Health Care Workers of a Specialist Hospital in Nigeria

Abstract: Background: Healthcare workers (HCWs) are at increased risk of contracting HBV infection from occupational exposure. In spite of this, many HCWs are often not keen on getting vaccinated. Studies have reported the perception of risk among other factors as frequent reasons against Vaccination. The aim of this study was to assess the perceived risk, willingness for vaccination and uptake of hepatitis B vaccine among HCWs of a specialist hospital in Nigeria. Methodology: The study was conducted among 209 HCWs of a specialist hospital, Ondo state, Nigeria. A hospital based cross-sectional design, with structured questionnaire used in data collection. Descriptive statistics were used to identify general characteristics of the sample. Bivariate analysis and binary logistic regression were also performed. Results: About 62.7% of HCWs perceived self to be at high risk of contracting HBV while 37.3% perceived self to be at low risk. Ninety-seven percent of the HCWs were willing to receive the vaccine although 31.1% had fears about the side effects of the vaccine. Knowledge of HBV, educational level, age, and duration of practice were significantly associated with perceived risk. Perceived risk of contracting HBV (Adjusted odds ratio (AOR) 2.01, 95% confidence interval (CI) 1.20-6.20), knowledge of HBV (AOR 1.50, 95% CI 1.31-5.84) and HCWs educational level (AOR 1.55, 95% CI 1.02-4.51) were identified as predictors of willingness for vaccination. Conclusions: Perception of risk for HBV among HCWs was relatively low although willingness for vaccination was high. Intervention to improve perception and correct fears are required.

Incidence of Onchocerciasis and Vector Knowledge among Residents of Some Parts of Ondo State, Nigeria

Abstract: Onchocerciasis, cause by Onchocerca volvulus is a typical filarial nematode that is known to be primarily a parasite of humans. This study was carried out to determine the incidence of O. volvulus and knowledge of its vector in Ido-ani and Akure the capital of Ondo State, Nigeria. Skin snips were collected from individuals in Idoani andmicroscopically examined for presence of microfilariae while structured questionnaires were administered on respondents in Akure. The result showed that 75% of the skin snips collected from Ido-ani had O. volvulus microfilariae, while 76% of the respondents consented to being aware of onchocerciasis, more than half (56%) of whom are aged 21-30 years. Forty eight percent (48%) were able to identify black flies while only 42% were aware that black fly cause a disease known as river blindness, and 21% respondent neither had knowledge of the disease nor its vector. Findings of this study underscores the urgent need for the intensification of awareness campaigns in order to educate the population about Onchocerciasis and ways of preventing the infection.

Opening the Door to Funny Turns: A Constructivist Thematic Analysis of Patient Narratives after TIA

Abstract: Introduction: It is crucial to enhance timely treatment and secondary prevention following a transient ischaemic attack (TIA) and one way to ensure this is to improve the accuracy and promptness of diagnosis. Unfortunately, initiating timely treatment can be difficult due to patients’ lack of knowledge of symptoms and their need for urgency, and difficulties in obtaining this diagnosis. Understanding the TIA event from the patient’s perceptive may open the door to a better understanding of TIA symptomology and improve current difficulties with diagnosis. Method: Narratives of 123 participants, adjudicated to have experienced a TIA, were selected from a TIA/minor stroke cohort assembled by the International Study of Systems of Care in Minor Stroke and TIA [InSiST] study. This National Health and Medical Research Council (NHMRC) funded study is currently underway in NSW, Australia. The participants’ TIA experiences were transcribed into narratives, and using constructivist thematic analysis, an insightful description of patient perceptions of, and responses to, their TIA symptoms was obtained. Results: Participants described mental checklists they created in response to their symptoms that reflected the scope of what they knew about TIA/stroke symptoms. Deficits in TIA-specific knowledge were apparent in these lists, which influenced the participants’ responses to their symptoms. Surprisingly, many participants felt they needed to experience all the symptoms on their checklist before they acted. Confusion also arose around additional symptoms, inability to describe symptoms and temporary nature of symptoms, which tended to de-escalate the seriousness of symptoms. These disparities also aided self-attribution of a range of erroneous diagnoses and inhibited appropriate actions. Commonalities in the shared experience of participants also emerged which hindered the participants physical or cognitive capabilities to seek medical treatment. These commonalities included sudden loss of language and bodily control, inability to complete tasks, no awareness of symptoms, or loss of consciousness. This rendered the participants reliant on significant others to gain urgent medical treatment. Conclusion: Health professionals’ identification and acknowledgement of these subjective experiences may add a broader awareness of TIA symptoms at presentation and contribute to more accurate detection or diagnoses of TIA events. The identification of knowledge deficits in people’s utilisation of stroke checklists has implications for both current and future public health stroke campaigns in raising awareness of TIA symptoms. Further studies to explore the subjective experiences of TIA would be beneficial to enhance our understanding of TIA.