Showing papers in "Public Health Research in 2018"

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Abstract: Background Approximately one-third of children in England leave primary school overweight or obese There is little evidence of effective obesity prevention programmes for children in this age group Objective To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years Design A cluster randomised controlled trial with an economic and process evaluation Setting Thirty-two primary schools in south-west England Participants Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up Intervention The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities Main outcome measures The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention) The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness Results We recruited 32 schools and 1324 children We had a rate of 94% follow-up for the primary outcome No difference in BMI SDS was found at 24 months [mean difference –002, 95% confidence interval (CI) –009 to 005] or at 18 months (mean difference –002, 95% CI –008 to 005) between children in the intervention schools and children in the control schools No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’ The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’ The cost of implementing the intervention was approximately £210 per child The intervention was not cost-effective compared with control The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum Limitations The rate of response to the parent questionnaire in the process evaluation was low Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average Conclusions HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years Future work Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity Trial registration Current Controlled Trials ISRCTN15811706 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 6, No 1 See the NIHR Journals Library website for further project information

Health impact, and economic value, of meeting housing quality standards: a retrospective longitudinal data linkage study

Abstract: Background Poor-quality housing adversely affects residents’ health but there is a paucity of high-quality evidence to support this. Objective This research investigated the health impact of bringing housing to a national quality standard. Design A natural experiment of improvements to housing quality analysed using repeated measures of health-care utilisation and economic outcomes at an individual person level. Setting Carmarthenshire, UK. Participants A total of 32,009 residents registered for a minimum of 60 days at 8558 social homes that received housing improvements between January 2005 and March 2015. Interventions Multiple internal and external housing improvements, including wall and loft insulation, windows and doors, heating system upgrades, new kitchens and bathrooms, garden path safety improvements and electrical system upgrades (adding power sockets, and extractor fans in kitchens and bathrooms). Main outcome measures Emergency hospital admissions for cardiorespiratory conditions and injuries. Primary health-care utilisation for respiratory and common mental health disorders, emergency department injury attendances and health-care utilisation costs. Data sources Carmarthenshire County Council home address and intervention records were anonymously linked within the Secure Anonymous Information Linkage databank to demographic information from the Welsh Demographic Service data set; hospital admission data from the Patient Episode Dataset for Wales; primary care contacts and prescribed medications from general practice data; emergency department attendances from the Emergency Department Data Set; and deaths from the Office for National Statistics mortality register. Methods The study used a longitudinal panel design to examine changes in standard of eight housing cointervention from intervention records, and linked to individuals registered at intervention homes. Health outcomes were obtained retrospectively for each individual in a dynamic cohort and were captured for up to 123 consecutive months. An additional local authority region could not be utilised as a comparator owing to different reporting pressures resulting in the recording of a different intervention. The exposure group for each cointervention was compared with an internal reference group of people living in homes that did not receive the cointervention during their tenancy. A multilevel modelling approach was used to account for repeated observations for individuals living in intervention homes. Counts of health outcomes were analysed using negative binomial regression models to determine the effect of each cointervention that reached housing quality standards during an individual’s period of tenancy, compared with those living in properties that did not. We adjusted for potential confounding factors and for background trends in the regional general population. A cost–consequences analysis was conducted as part of the health economic evaluation. Results Residents aged ≥ 60 years living in homes in which electrical systems were upgraded were associated with 39% fewer admissions than those living in homes in which they were not [incidence rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.53 to 0.72; p < 0.01]. Reduced admissions were also associated with windows and doors (IRR 0.71, 95% CI 0.63 to 0.81; p < 0.01), wall insulation (IRR 0.75, 95% CI 0.67 to 0.84; p < 0.01) and gardens and estates (IRR 0.73, 95% CI 0.64 to 0.83; p < 0.01) for those living in homes in which these cointervention were upgraded. There were no associations of change in emergency admissions with upgrading heating (IRR 0.91, 95% CI 0.82 to 1.01; p = 0.072), loft insulation (IRR 0.98, 95% CI 0.86 to 1.11; p = 0.695), kitchens (IRR 0.98, 95% CI 0.83 to 1.17; p = 0.843) or bathrooms (IRR 0.93, 95% CI 0.81 to 1.06; p = 0.287). Limitations There was no randomisation, there were incomplete data on the scale of the intervention for individual households and there were no estimates for the impact of the whole programme. Conclusions This complex interdisciplinary study found that hospital admissions could be avoided through improving housing quality standards.

Long-term weight loss following a randomised controlled trial of a weight management programme for men delivered through professional football clubs : the Football Fans in Training follow-up study

Abstract: Background Rising levels of obesity require interventions that support people in long-term weight loss. The Football Fans in Training (FFIT) programme uses loyalty to football teams to engage men in weight loss. In 2011/12, a randomised controlled trial (RCT) found that the FFIT programme was effective in helping men lose weight up to 12 months. Objectives To investigate the long-term weight, and other physical, behavioural and psychological outcomes up to 3.5 years after the start of the RCT; the predictors, mediators and men’s qualitative experiences of long-term weight loss; cost-effectiveness; and the potential for long-term follow-up via men’s medical records. Design A mixed-methods, longitudinal cohort study. Setting Thirteen professional Scottish football clubs from the RCT and 16 additional Scottish football clubs that delivered the FFIT programme in 2015/16. Participants A total of 665 men who were aged 35–65 years at the RCT baseline measures and who consented to follow-up after the RCT (intervention group, n = 316; comparison group, n = 349), and 511 men who took part in the 2015/16 deliveries of the FFIT programme. Interventions None as part of this study. Main outcome measures Objectively measured weight change from the RCT baseline to 3.5 years. Results In total, 488 out of 665 men (73.4%) attended 3.5-year measurements. Participants in the FFIT follow-up intervention group sustained a mean weight loss from baseline of 2.90 kg [95% confidence interval (CI) 1.78 to 4.02 kg; p < 0.001], and 32.2% (75/233) weighed ≥ 5% less than at baseline. Participants in the FFIT follow-up comparison group (who participated in routine deliveries of the FFIT programme after the RCT) lost a mean of 2.71 kg (95% CI 1.65 to 3.77 kg; p < 0.001), and 31.8% (81/255) achieved ≥ 5% weight loss. Both groups showed long-term improvements in body mass index, waist circumference, percentage body fat, blood pressure, self-reported physical activity (PA) (including walking), the consumption of fatty and sugary foods, fruit and vegetables and alcohol, portion sizes, self-esteem, positive and negative affect, and physical and mental health-related quality of life (HRQoL). Mediators included self-reported PA (including walking) and sitting time, the consumption of fatty and sugary foods and fruit and vegetables, portion sizes, self-esteem, positive affect, physical HRQoL, self-monitoring of weight, autonomous regulation, internal locus of control, perceived competence, and relatedness to other FFIT programme participants and family members. In qualitative interviews, men described continuing to self-monitor weight and PA. Many felt that PA was important for weight control, and walking remained popular; most were still aware of portion sizes and tried to eat fewer snacks. The FFIT programme was associated with an incremental cost-effectiveness of £10,700–15,300 per quality-adjusted life-year (QALY) gained at 3.5 years, and around £2000 per QALY gained in the lifetime analysis. Medical record linkage provided rich information about the clinical health outcomes of the FFIT RCT participants, and 90% of men (459/511) who took part in the 2015/16 FFIT programme gave permission for future linkage. Conclusions Participation in the FFIT programme under both research (during the FFIT RCT) and routine (after the FFIT RCT) delivery conditions led to significant long-term weight loss. Further research should investigate (1) how to design programmes to improve long-term weight loss maintenance, (2) longer-term follow-up of FFIT RCT participants and (3) very long-term follow-up via medical record linkage. Trial registration Current Controlled Trials ISRCTN32677491. 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. 6, No. 9. See the NIHR Journals Library website for further project information. The Scottish Executive Health Department Chief Scientist Office (CSO) funded the feasibility pilot that preceded the FFIT RCT (CZG/2/504). The Medical Research Council (MRC) funded Kate Hunt and additional developmental research through the MRC/CSO Social and Public Health Sciences Unit Gender and Health programme (5TK50/25605200-68094).

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Abstract: The study found improvements in subjective well-being and a number of psychosocial outcomes, but there was no evidence of changes in physical health.

Child food insecurity in the UK: a rapid review

Abstract: Background Food insecurity (FI) is a multifaceted, socioeconomic problem involving difficulties accessing sufficient, safe and nutritious food to meet people’s dietary requirements and preferences for a healthy life. For children experiencing FI, there are some potentially negative developmental consequences and it is, therefore, important to understand the links between FI and children’s health and well-being as well as any strategies undertaken to address FI. The overall objective of this assessment was to determine the nature, extent and consequences of FI affecting children (aged ≤ 18 years) in the UK. Objective To determine the nature, extent and consequences of FI affecting children (aged ≤ 18 years) in the UK. Data sources The databases searched on 4 December 2017 included MEDLINE (including In-Process & Other Non-Indexed Citations and E-pub ahead of print files), EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Commonwealth Agricultural Bureaux (CAB) abstracts, The Cochrane Library, Education Resources Information Centre (ERIC), PsycINFO, the Social Science Citation Index and the Applied Social Sciences Index and Abstracts (ASSIA). Methods A rapid review of the current published and unpublished literature was conducted, including all study designs from specified high-income countries in children aged ≤ 18 years. Searches were conducted of major health-care, nutrition, education and social science databases from 1995 onwards, and websites of relevant UK and international organisations. Final searches were undertaken in December 2017. Results In total, 109 studies were selected. Only five studies were conducted in the UK, four of which provided qualitative data. Possible factors associated with child FI were identified, for example socioeconomic status, material deprivation, living in public housing and having unemployed or poorly educated parents. Children’s health, well-being and academic outcomes were all negatively affected by FI. The mediating effects of family stressors and parenting practices in the relationship between FI and children’s health and well-being outcomes were not clear. Food assistance programmes were generally effective in mitigating FI and improving nutritional outcomes (including hunger) in the short term, but did not eradicate FI, eliminate its effects on children’s health or have an impact on academic outcomes. No reports assessing the prevalence of child FI in the UK or the cost-effectiveness and sustainability of interventions to tackle FI were identified. Limitations There was a lack of consistency in how FI was defined and measured across studies. Most of the studies used indirect measurements of child FI through parental reports. The majority of studies were conducted in North America. Only five studies were conducted in the UK. Thirty potentially relevant studies were not included in the review as a result of time and resource constraints. Most studies were observational and caution is advised in interpreting their results. Conclusions A number of factors that were related to child FI were identified, as were negative associations between child FI and physical, mental and social outcomes. However, these findings should be interpreted with caution because of the correlational nature of the analyses and the fact that it is difficult to determine if some factors are predictors or consequences of FI. Future research There is an urgent requirement for the development of a reliable instrument to measure and monitor child FI in the UK and for well-designed interventions or programmes to tackle child FI. Study registration This study is registered as PROSPERO CRD42017084818. Funding The National Institute for Health Research Public Health Research programme. The Health Services Research Unit is core-funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

Mass Media for Public Health Messages: Reviews of the Evidence

Abstract: Background: Mass media campaigns can be used to communicate public health messages at the population level. Although previous research has shown that they can influence health behaviours in some contexts, there have been few attempts to synthesise evidence across multiple health behaviours. Objectives: To: review evidence on the effective use of mass media in six health topic areas (alcohol, diet, illicit drugs, physical activity, sexual and reproductive health, and tobacco); examine whether effectiveness varies with different target populations; identify characteristics of mass media campaigns associated with effectiveness; and identify key research gaps. Design: (A) A systematic review of reviews; (B) a review of primary studies examining alcohol mass media campaigns; (C) a review of cost-effectiveness evidence; (D) a review of recent primary studies of mass media campaigns conducted in the UK. A logic model was developed to inform the reviews. Public engagement activities were conducted with policy, practitioner and academic stakeholders and with young people. Results: The amount and strength of evidence varies across the six topics, and there was little evidence regarding diet campaigns. There was moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment-seeking behaviours (eg. use of smoking quitlines and sexual health services). Impact on tobacco use and physical activity was mixed, there was limited evidence of impact on alcohol use and no impact on illicit drug behaviours. Mass media campaigns were found to increase knowledge and awareness across several topics, and to influence intentions regarding physical activity and smoking. Tobacco and illicit drug campaigns appeared to be more effective for young people and children but there was no or inconsistent evidence regarding effectiveness by gender, ethnicity or socio-economic status. There was moderate evidence that tobacco mass media campaigns are cost-effective, but weak or limited evidence in other topic areas. Although there was limited evidence on characteristics associated with effectiveness, longer or greater intensity campaigns were found to be more effective, and messages were important, with positive and negative messages and social norms messages affecting smoking behaviour. The evidence suggested that targeting messages to target audiences can be effective. There was little evidence from regarding the role that theory or media channels may play in campaign effectiveness, and also limited evidence on new media. Limitations: Statistical synthesis was not possible due to considerable heterogeneity across reviews and studies. The focus on review-level evidence limited our ability to examine intervention characteristics in detail. Conclusions: Overall the evidence is mixed but suggests that: campaigns can reduce sedentary behaviour, improve sexual health and contribute to smoking cessation; tobacco control campaigns can be cost-effective; longer and more intensive campaigns are likely to be more effective; message design and targeting campaigns to particular population groups can be effective. Future work: Future work could fill evidence gaps regarding diet mass media campaigns and new media campaigns, examine cost-effectiveness in areas other than tobacco, and explore the specific contribution of mass media campaigns to multi-component interventions and how local, regional and national campaigns can work together. This study is registered as PROSPERO CRD42015029205 and PROSPERO CRD42017054999.

The PATHS curriculum for promoting social and emotional well-being among children aged 7 9 years: a cluster RCT

Abstract: Background Universal social and emotional learning interventions can produce significant practical improvements in children’s social skills and other outcomes. However, the UK evidence base remains limited. Objectives To investigate the implementation, impact and cost-effectiveness of the Promoting Alternative THinking Strategies (PATHS) curriculum. Design Cluster randomised controlled trial. Primary schools (n = 45) were randomly assigned to implement PATHS or to continue with their usual provision for 2 years. Setting Primary schools in seven local authorities in Greater Manchester. Participants Children (n = 5218) in Years 3–5 (aged 7–9 years) attending participating schools. Intervention PATHS aims to promote children’s social skills via a taught curriculum, which is delivered by the class teacher, generalisation activities and techniques, and supplementary materials for parents. Schools in the usual provision group delivered the Social and Emotional Aspects of Learning programme and related interventions. Main outcome measures Children’s social skills (primary outcome, assessed by the Social Skills Improvement System); pro-social behaviour and mental health difficulties (Strengths and Difficulties Questionnaire); psychological well-being, perceptions of peer and social support, and school environment (Kidscreen-27); exclusions, attendance and attainment (National Pupil Database records); and quality-adjusted life-years (QALYs) (Child Health Utility 9 Dimensions). A comprehensive implementation and process evaluation was undertaken, involving usual provision surveys, structured observations of PATHS lessons, interviews with school staff and parents, and focus groups with children. Results There was tentative evidence (at a p-value of < 0.10) that PATHS led to very small improvements in children’s social skills, perceptions of peer and social support, and reductions in exclusions immediately following implementation. A very small but statistically significant improvement in children’s psychological well-being [d = 0.12, 95% confidence interval (CI) –0.02 to 0.25; p < 0.05) was also found. No lasting improvements in any outcomes were observed at 12- or 24-month post-intervention follow-up. PATHS was implemented well, but not at the recommended frequency; our qualitative analysis revealed that this was primarily due to competing priorities and pressure to focus on the core academic curriculum. Higher levels of implementation quality and participant responsiveness were associated with significant improvements in psychological well-being. Finally, the mean incremental cost of PATHS compared with usual provision was determined to be £29.93 per child. Mean incremental QALYs were positive and statistically significant (adjusted mean 0.0019, 95% CI 0.0009 to 0.0029; p < 0.05), and the incremental net benefit of introducing PATHS was determined to be £7.64. The probability of cost-effectiveness in our base-case scenario was 88%. Limitations Moderate attrition through the course of the main trial, and significant attrition thereafter (although this was mitigated by the use of multiple imputation of missing data); suboptimal frequency of delivery of PATHS lessons. Conclusions The impact of PATHS was modest and limited, although that which was observed may still represent value for money. Future work should examine the possibility of further modifications to the intervention to improve goodness of fit with the English school context without compromising its efficacy, and identify whether or not particular subgroups benefit differentially from PATHS. Trial registration Current Controlled Trials ISRCTN85087674 (the study protocol can be found at: www.journalslibrary.nihr.ac.uk/programmes/phr/10300601/#/). 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 6, No. 10. See the NIHR Journals Library website for further project information.

Text message intervention to reduce frequency of binge drinking among disadvantaged men: the TRAM RCT

Abstract: Background Socially disadvantaged men are more likely to binge drink frequently and to experience high levels of alcohol-related harm. Objectives To test the effectiveness and cost-effectiveness of a text message intervention in reducing the frequency of binge drinking among disadvantaged men. Study design A four-centre, parallel-group, pragmatic, individually randomised controlled trial was conducted. Randomisation was carried out using a secure remote web-based system. It was stratified by participating centre and recruitment method and restricted using block sizes of randomly varying lengths. Setting The study was conducted in the community. Members of the public helped to develop the study methods. Participants Participants were men aged 25–44 years who had ≥ 2 episodes of binge drinking (> 8 units of alcohol in a single session) in the preceding 28 days. Men were recruited from areas of high deprivation. Interventions An empirically and theoretically based text message intervention was delivered by 112 interactive text messages over a 12-week period. The control group received an attentional control comprising 89 text messages on general health. Primary outcome measure The primary outcome measure was the proportion of men consuming > 8 units of alcohol on ≥ 3 occasions (in the previous 28 days) at 12 months post intervention. Results The recruitment target of 798 was exceeded and 825 men were randomised. Retention was high and similar in the intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged enthusiastically with the text messages: almost all (92%) replied to text messages and over two-thirds (67%) replied more than 10 times. The intervention was estimated to have had a modest, statistically non-significant effect on the primary outcome at the 12-month follow-up [odds ratio 0.79, 95% confidence interval (CI) 0.57 to 1.08]. This corresponds to a net reduction of 5.7% in regular binge drinking. Five secondary outcomes showed small non-significant and inconsistent effects on alcohol consumption, with one suggesting a positive effect and four suggesting an adverse effect. Both the short- and the long-term cost per quality-adjusted life-year (QALY) analysis suggested that the brief intervention was dominated by a ‘do-nothing’ option. The intervention’s impacts on patterns of alcohol consumption, QALYs and downstream costs were inconsistent and uncertain. Limitations The study used an active control that, combined with the recruitment procedures and baseline assessments, could have biased the treatment effect towards the null. The measurement of alcohol consumption relied on self-reported drinking. Conclusions The trial has demonstrated that it is possible to recruit and retain large numbers of socially disadvantaged men in a research study. The text messages delivered a complex theoretically and empirically based intervention that fostered enthusiastic engagement with the key components of the behaviour change sequence. The intervention produced a modest, statistically non-significant effect on the primary outcome, with wide CIs. Further research is needed to reduce uncertainty about the treatment effect. The methods developed for this study provide a platform for the design and testing of interventions to reduce inequalities in health. Future work A future trial could reduce the uncertainty around the treatment effect of the intervention. Trial registration Current Controlled Trials ISRCTN07695192. Funding This study 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. 6, No. 6. See NIHR Journals Library website for further information.

The impact of home energy efficiency interventions and winter fuel payments on winter- and cold-related mortality and morbidity in England: a natural equipment mixed-methods study

Abstract: Background England, and the UK more generally, has a large burden of winter- and cold-related mortality/morbidity in comparison with nearby countries in continental Europe. Improving the energy efficiency of the housing stock may help to reduce this, as well as being important for climate change and energy security objectives. Objectives To evaluate the impact of home energy efficiency (HEE) interventions on winter- and cold-related mortality/morbidity, including assessing the impact of winter fuel payments (WFPs) and fuel costs. Design A mixed-methods study – an epidemiological time-series analysis, an analysis of data on HEE interventions, the development and application of modelling methods including a multicriteria decision analysis and an in-depth interview study of householders. Setting England, UK. Participants The population of England. In-depth interviews were conducted with 12 households (2–4 participants each) and 41 individuals in three geographical regions. Interventions HEE interventions. Main outcome measures Mortality, morbidity and intervention-related changes to the home indoor environment. Data sources The Homes Energy Efficiency Database, mortality and hospital admissions data and weather (temperature) data. Results There has been a progressive decline in cold-related deaths since the mid-1970s. Since the introduction of WFPs, the gradient of association between winter cold and mortality [2.00%, 95% confidence interval (CI) 1.74% to 2.28%] per degree Celsius fall in temperature is somewhat weaker (i.e. that the population is less vulnerable to cold) than in earlier years (2.37%, 95% CI 0.22% to 2.53%). There is also evidence that years with above-average fuel costs were associated with higher vulnerability to outdoor cold. HEE measures installed in England in 2002–10 have had a relatively modest impact in improving the indoor environment. The gains in winter temperatures (around +0.09 °C on a day with maximum outdoor temperature of 5 °C) are associated with an estimated annual reduction of ≈280 cold-related deaths in England (an eventual maximum annual impact of 4000 life-years gained), but these impacts may be appreciably smaller than those of changes in indoor air quality. Modelling studies indicate the potential importance of the medium- and longer-term impacts that HEE measures have on health, which are not observable in short-term studies. They also suggest that HEE improvements of similar annualised cost to current WFPs would achieve greater improvements in health while reducing (rather than increasing) carbon dioxide emissions. In-depth interviews suggest four distinct householder framings of HEE measures (as home improvement, home maintenance, subsidised public goods and contributions to sustainability), which do not dovetail with current ‘consumerist’ national policy and may have implications for the uptake of HEE measures. Limitations The quantification of intervention impacts in this national study is reliant on various indirect/model-based assessments. Conclusions Larger-scale changes are required to the housing stock in England if the full potential benefits for improving health and for reaching increasingly important climate change mitigation targets are to be realised. Future work Studies based on data linkage at individual dwelling level to examine health impacts. There is a need for empirical assessment of HEE interventions on indoor air quality. 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. 6, No. 11. See the NIHR Journals Library website for further project information.

A cluster randomised controlled trial and evaluation and cost-effectiveness analysis of the Roots of Empathy schools-based programme for improving social and emotional well-being outcomes among 8- to 9-year-olds in Northern Ireland

Abstract: Background There is growing consensus regarding the importance of attending to children’s social and emotional well-being. There is now a substantial evidence base demonstrating the links between a child’s early social and emotional development and a range of key longer-term education, social and health outcomes. Universal school-based interventions provide a significant opportunity for early intervention in this area and yet the existing evidence base, particularly in relation to their long-term effects, is limited. Objectives and main outcomes To determine the effectiveness and cost-effectiveness of Roots of Empathy (ROE), a universal school-based programme that, through attempting to enhance children’s empathy, seeks to achieve the following two main outcomes: improvement in prosocial behaviour and reduction in difficult behaviour. Design A cluster randomised controlled trial and an economic evaluation. A total of 74 primary schools were randomly assigned to deliver ROE or to join a waiting list control group. Seven schools withdrew post randomisation and a further two withdrew before the immediate post-test time point. Children (n = 1278) were measured pre test and immediately post test, and then for 3 years following the end of the programme. Data were also collected from teachers and parents. Setting and participants The intervention schools delivered ROE to their Year 5 children (aged 8–9 years) as a whole class. Intervention ROE is delivered on a whole-class basis for one academic year (October–June). It consists of 27 lessons based around the monthly visit from a baby and parent who are usually recruited from the local community. Children learn about the baby’s growth and development and are encouraged to generalise from this to develop empathy towards others. Results Although it was developed in Canada, the programme was very well received by schools, parents and children, and it was delivered effectively with high fidelity. ROE was also found to be effective in achieving small improvements in children’s prosocial behaviour (Hedges’ g = 0.20; p = 0.045) and reductions in their difficult behaviour (Hedges’ g = –0.16; p = 0.060) immediately post test. Although the gains in prosocial behaviour were not sustained after the immediately post-test time point, there was some tentative evidence that the effects associated with reductions in difficult behaviour may have remained up to 36 months from the end of the programme. These positive effects of ROE on children’s behaviour were not found to be associated with improvements in empathy or other social and emotional skills (such as emotional recognition and emotional regulation), on which the trial found no evidence of ROE having an effect. The study also found that ROE was likely to be cost-effective in line with national guidelines. Conclusions These findings are consistent with those of other evaluations of ROE and suggest that it is an effective and cost-effective programme that can be delivered appropriately and effectively in regions such as Northern Ireland. A number of issues for further consideration are raised regarding opportunities to enhance the role of parents; how a time-limited programme such as ROE can form part of a wider and progressive curriculum in schools to build on and sustain children’s social and emotional development; and the need to develop a better theory of change for how ROE works. Trial registration Current Controlled Trials ISRCTN07540423. 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. 6, No. 4. See the NIHR Journals Library website for further project information.

The effects of the London 2012 Olympics and related urban regeneration on physical and mental health: the ORiEL mixed-methods evaluation of a natural experiment

Abstract: Background There is limited evidence for public health policy-makers on the health impacts of urban regeneration programmes. Objectives To assess whether or not the London 2012 Olympic and Paralympic Games, and related urban regeneration, were associated with an increase in physical activity and mental health and well-being; to assess whether or not any benefits were sustained over time; and to capture the experiences of residents of the Olympic host boroughs. Design Quasi-experimental prospective cohort study of adolescents and their parents/carers, with a nested qualitative longitudinal study of families. Setting London boroughs of Newham, Barking and Dagenham, Tower Hamlets and Hackney. Participants A cohort of 2254 adolescents in 25 schools; a repeat cross-sectional study of parents/carers and a sample of 20 families for the qualitative study. Intervention The London 2012 Olympic and Paralympic Games, and urban regeneration primarily associated with the redevelopment of the Olympic Park for legacy use. Primary outcome measures Change in the proportion of respondents meeting physical activity recommendations (using self-reported physical activity); change in the proportion of respondents reporting depression and anxiety and change in well-being score. Main results At 6 months, adolescents who became inactive were less likely to come from the intervention borough (Newham) than from comparison boroughs [risk ratio (RR) = 0.69, 95% confidence interval (CI) 0.51 to 0.93]. At 18 months, there were no statistically significant differences between intervention and comparison boroughs for all adolescent physical activity and screen-time transitions. Those who visited the Olympic Park more than once a month were the least likely to remain inactive (RR 0.11, 95% CI 0.02 to 0.48) and the least likely to become inactive (RR 0.38, 95% CI 0.24 to 0.60) compared with those who were active at baseline and at the 18-month follow-up. No impacts on parental/carer physical activity were observed. Adolescents who were ‘no longer depressed’ (RR 1.53, 95% CI 1.07 to 2.20) or ‘remained depressed’ (RR 1.78, 95% CI 1.12 to 2.83) at 6 months were more likely to be from the intervention borough. For well-being, there was no association between boroughs and change in well-being between baseline and the 6-month follow-up. At 18 months’ follow-up, adolescents who ‘remained depressed’ (RR 1.93, 95% CI 1.01 to 3.70) were more likely to be from the intervention borough than from comparison boroughs. No associations were observed for well-being at 18 months. There was limited evidence of change for parental mental health and well-being. The qualitative study found that residents generally welcomed the unexpected chance to live in a cleaner, safer and more unified environment. The findings suggested that the Games temporarily alleviated certain stressors in the social and physical environment. Overall, the Games lessened participants’ sense of social exclusion and appeared to generate a sense of inclusion and respite, even if this was only temporary. Study limitations include the potential for adolescents to not be assigned the correct level of exposure to urban regeneration and the effect of reductions in central and local public budgets owing to the UK Government’s deficit reduction programme. Conclusions This study provided the highest quality data to date on the short- and medium-term social and health impacts of sporting mega-events. We found limited evidence that the London 2012 Olympic and Paralympic Games had a positive effect on adolescent or parental physical activity, mental health or well-being. Funding The National Institute for Health Research Public Health Research programme.

Knowledge, Perception and Uptake of Prostate Cancer Screening: A Cross Sectional Study at a Level III Hospital in Kenya

Abstract: Objective: The aim of the study was to assess the Knowledge, Perception and Uptake of Prostate Cancer Screening among men attending Mathare North Health Centre. Methods: This was a Descriptive cross-sectional facility based study. The study was conducted at Mathare Health Centre in Nairobi County in Kenya among men aged 30 years and above attending the facility outpatient department. Quantitative data was collected using a structured interview based questionnaire. Data was analysed by use of Statistical Package for Social Scientists (SPSS) version 22. Results: Eighty percent (80%) of the respondents were aware of prostate cancer existence with the mass media being the major source of the information. Knowledge on various domains was low as 87% of the respondents were not aware of the symptoms of prostate cancer, 52% did not know that the disease is preventable while 71% did not know the disease is curable. Sixty four percent (64%) of the respondents were not aware of existence of prostate cancer screening services, 63% of the respondents perceived themselves as not being at risk of developing the disease while 8.8% of the respondents perceived themselves as being susceptible to prostate cancer in the future. The respondents (62.2%) held fatalistic beliefs towards prostate cancer. Only 1.3% of the respondents had undergone screening which was done more than three years preceding the study. Conclusion: The level of awareness of prostate cancer was high while knowledge on the various domains was low. There was low perception of self-vulnerability and existence of fatalistic beliefs. Consistent with the low level of knowledge, low perception of self- vulnerability, the uptake of prostate cancer was extremely low. There is need to Scale up health education to the community regarding prostate cancer to enhance knowledge, eliminate negative beliefs and increase the uptake of screening.

Collaborative case management to aid return to work after long-term sickness absence: a pilot randomised controlled trial

Abstract: Background: Despite high levels of employment among working-age adults in the UK, there is still a significant minority who are off work with ill health at any one time (so-called ‘sickness absence’). Long-term sickness absence results in significant costs to the individual, to the employer and to wider society. Objective: The overall objective of the intervention was to improve employee well-being with a view to aiding return to work. To meet this aim, a collaborative case management intervention was adapted to the needs of UK employees who were entering or experiencing long-term sickness absence. Design: A pilot randomised controlled trial, using permuted block randomisation. Recruitment of patients with long-term conditions in settings such as primary care was achieved by screening of routine records, followed by mass mailing of invitations to participants. However, the proportion of patients responding to such invitations can be low, raising concerns about external validity. Recruitment in the Case Management to Enhance Occupational Support (CAMEOS) study used this method to test whether or not it would transfer to a population with long-term sickness absence in the context of occupational health (OH). Participants: Employed people on long-term sickness absence (between 4 weeks and 12 months). The pilot was run with two different collaborators: a large organisation that provided OH services for a number of clients and a non-profit community-based organisation. Intervention: Collaborative case management was delivered by specially trained case managers from the host organisations. Sessions were delivered by telephone and supported use of a self-help handbook. The comparator was usual care as provided by participants’ general practitioner (GP) or OH provider. This varied for participants according to the services available to them. Neither participants nor the research team were blind to randomisation.

Public health air pollution impacts of pathway options to meet the 2050 UK Climate Change Act target: a modelling study

Abstract: Background The UK’s Climate Change Act 2008 (CCA; Great Britain. Climate Change Act 2008. Chapter 27. London: The Stationery Office; 2008) requires a reduction of 80% in carbon dioxide-equivalent emissions by 2050 on a 1990 base. This project quantified the impact of air pollution on health from four scenarios involving particulate matter of ≤ 2.5 µm (PM2.5), nitrogen dioxide (NO2) and ozone (O3). Two scenarios met the CCA target: one with limited nuclear power build (nuclear replacement option; NRPO) and one with no policy constraint on nuclear (low greenhouse gas). Another scenario envisaged no further climate actions beyond those already agreed (‘baseline’) and the fourth kept 2011 concentrations constant to 2050 (‘2011’). Methods The UK Integrated MARKAL–EFOM System (UKTM) energy system model was used to develop the scenarios and produce projections of fuel use; these were used to produce air pollutant emission inventories for Great Britain (GB) for each scenario. The inventories were then used to run the Community Multiscale Air Quality model ‘air pollution model’ to generate air pollutant concentration maps across GB, which then, combined with relationships between concentrations and health outcomes, were used to calculate the impact on health from the air pollution emitted in each scenario. This is a significant improvement on previous health impact studies of climate policies, which have relied on emissions changes. Inequalities in exposure in different socioeconomic groups were also calculated, as was the economic impact of the pollution emissions. Results Concentrations of NO2 declined significantly because of a high degree of electrification of the GB road transport fleet, although the NRPO scenario shows large increases in oxides of nitrogen emissions from combined heat and power (CHP) sources. Concentrations of PM2.5 show a modest decrease by 2050, which would have been larger if it had not been for a significant increase in biomass (wood burning) use in the two CCA scenarios peaking in 2035. The metric quantifying long-term exposure to O3 is projected to decrease, while the important short-term O3 exposure metric increases. Large projected increases in future GB vehicle kilometres lead to increased non-exhaust PM2.5 and particulate matter of ≤ 10 µm emissions. The two scenarios which achieve the CCA target resulted in more life-years lost from long-term exposures to PM2.5 than in the baseline scenario. This is an opportunity lost and arises largely from the increase in biomass use, which is projected to peak in 2035. Reduced long-term exposures to NO2 lead to many more life-years saved in the ‘CCA-compliant’ scenarios, but the association used may overestimate the effects of NO2 itself. The more deprived populations are estimated currently to be exposed to higher concentrations than those less deprived, the contrast being largest for NO2. Despite reductions in concentrations in 2050, the most socioeconomically deprived are still exposed to higher concentrations than the less deprived. Limitations Modelling of the atmosphere is always uncertain; we have shown the model to be acceptable through comparison with observations. The necessary complexity of the modelling system has meant that only a small number of scenarios were run. Conclusions We have established a system which can be used to explore a wider range of climate policy scenarios, including more European and global scenarios as well as local measures. Future work could explore wood burning in more detail, in terms of the sectors in which it might be burned and the spatial distribution of this across the UK. Further analyses of options for CHP could also be explored. Non-exhaust emissions from road transport are an important source of particles and emission factors are uncertain. Further research on this area coupled with our modelling would be a valuable area of research. Funding The National Institute for Health Research Public Health Research programme.

Assessing the Effects of Fuel Based Lighting: The Case of Kerosene Use and Disasters in Nigeria

Abstract: Fuel based lighting made up of kerosene continues to find essential use in West Africa. In Nigeria where tens of millions regularly use kerosene, adverse environmental health effects remain widespread much of the time given the mixed results. These include rising mortality and morbidity often associated with fire hazards from kerosene explosions, destruction of properties, burns, compromised vision, indoor air pollution, asthma and the disproportionate exposure of infants and women to the risks of recurrent kerosene hazards. With hospital emergency cases involving complications from kerosene hazards on the rise, adulterated products in the face of loose regulations and mass poverty has surged over the years. In all these, very little research exists to assess the risks from fuel lighting incidents and their impacts from a mix scale perspective using GIS. Accordingly, this paper analyzes the growing risks from kerosene disasters in Nigeria. Emphasis is on the issues, the trends, factors and impacts using mix scale techniques of GIS and descriptive statistics to map and track the trends spatially. Preliminary results using descriptive statistics reveal kerosene hazards in the form of fatalities through household explosions as well as health and environmental risks. Just as impact analysis identified pollution threats, the GIS mapping pinpointed the spatial dispersion of the risks and elements associated with kerosene hazards. With all these attributed to several elements from ineffective policy to economic conditions, the paper offered several remedies consisting of the need for education and enlightenment campaign, coupled with improved emergency response to fire hazards and the strengthening of policy. In highlighting the extent of kerosene hazards in the country, there is opportunity for resource managers and decision-making to build from it and design proactive measures to mitigate future disasters for the safety of citizens.

Role of monetary incentives on motivation and retention of community health workers: an experience in a Kenyan community.

Abstract: Objective: The aim of the study was to assess the role of monetary incentives on motivation and retention of Community Health Workers in Kibwezi Sub-county. Methods: It was a cross-sectional comparative study in which retention of community health workers receiving monetary incentives and those not receiving monetary incentives was compared. Data was collected using a structured questionnaire, key informant interview guide and focus group discussion guide. Relationships between variables were determined using logistics regression Results: Monetary incentives were cited as the main motivator with majority of the CHWs reporting a salary as the factor that would motivate them the most. There was higher attrition rates (13%) among those not receiving any form of monetary incentives compared to those receiving monetary incentives (4%). There was a statistical significant difference in attrition rate between CHW’s receiving monetary incentives and those not receiving monetary incentives. 80% of CHWs not receiving monetary incentives had ever contemplated dropping out of their CHW roles compared to 66% among CHWs receiving monetary incentives. The main reasons cited for attrition of CHWs included financial constraints and inadequate compensation for work done. Conclusion: The study findings show that provision of monetary incentives has an influence on the attrition of CHWs. The attrition rates were higher for CHWs not receiving monetary incentives compared to CHWs receiving monetary incentives. Financial incentives are the most reported incentives to enhance the retention of CHWs. Provision of monetary incentives to CHWs should be explored to enhance their retention.

Knowledge and Attitude toward Zika Virus Disease among Pregnant Women in Iloilo City, Philippines

Abstract: The recent outbreak of Zika Virus Disease (ZVD) has caused global and local public health concerns especially among pregnant women and women of reproductive age. A descriptive-correlational survey was conducted to determine the knowledge and attitude toward ZVD among pregnant women in Iloilo City. Using a validated self-completion questionnaire, a total of 102 women seeking prenatal consultation in District Health Centers in Iloilo City were conveniently chosen as study participants. Descriptive and non-parametric inferential statistical tools were employed to analyze the data. Results indicated that the most common sources of information about ZVD were the television and radio. Majority of pregnant women had low level of knowledge but had positive attitude toward ZVD. Only a few knew that the disease can spread through sexual contact. While many pregnant women felt that ZVD is a serious disease that can cause serious problems to their babies, only a little more than half believed that they are susceptible of acquiring the disease. A significant relationship was found between knowledge about ZVD and attitude toward the disease. The findings suggest that public health intervention programs must address knowledge gaps and focus on correcting misconceptions to raise awareness and promote favorable attitude toward ZVD.

Impact and cost-effectiveness of care farms on health and well-being of offenders on probation: a pilot study

Abstract: Background Care farms (CFs), in which all or part of the farm is used for therapeutic purposes, show potential for improving well-being for disadvantaged groups. We assessed the feasibility of determining the cost-effectiveness of CFs in improving quality of life compared with comparator sites among probationers undertaking community orders (COs). Objectives (1) To conduct a systematic review of CF impacts and mechanisms in improving health and logic model development; (2) to inform future studies by estimating differences in quality of life and other outcomes, identifying factors driving CO allocation and ways to maximise recruitment and follow-up; and (3) to assess feasibility of cost-effectiveness analysis. Review methods A mixed-methods synthesis following Campbell Collaboration guidelines. Pilot study: three probation service regions in England, each with a CF and a comparator CO site. Participants were adult offenders (aged ≥ 18 years) serving COs. The primary outcome was quality of life [as measured via the Clinical Outcome in Routine Evaluation–Outcome Measure (CORE-OM)]. Other outcomes were health behaviours, mental well-being, connectedness to nature and reconvictions. Data sources In November 2014, we searched 22 health, education, environmental, criminal justice and social science electronic databases, databases of grey literature and care farming websites across Europe. There were no language restrictions. A full list of databases searched is given in Appendix 1; some examples include Web of Science, Cumulative Index to Nursing and Allied Health Literature (via EBSCOhost), The Campbell Library, Criminal Justice Abstracts (via EBSCOhost), MEDLINE (via Ovid) and Scopus (Elsevier B.V., Amsterdam, the Netherlands). Results Our systematic review identified 1659 articles: 14 qualitative, 12 quantitative and one mixed-methods study. Small sample sizes and poor design meant that all were rated as being at a high risk of bias. Components of CFs that potentially improve health are being in a group, the role of the farmer and meaningful work, and interaction with animals. There was a lack of quantitative evidence indicating that CFs improve quality of life and there was weak evidence of improved mental health, self-efficacy, self-esteem, affect and mood. In the pilot study we recruited 134 respondents, and only 21 declined; 37% were allocated to three CFs and the remainder to comparators. This was below our recruitment target of 300. Recruitment proved challenging as a result of the changes in probation (probation trusts were disbanded in 2014) and closure of one CF. We found significant differences between CFs and comparator users: those at CFs were more likely to be male, smokers, substance users, at higher risk of reoffending (a confounder) and have more missing CORE-OM questions. Despite these differences, the use of propensity analysis facilitated comparison. Participants consented to our team accessing, and we were able to link, probation and police reconviction data for 90% of respondents. We gained follow-up questionnaire data from 52% of respondents, including health and social care use cost data. We transformed CORE-OM into CORE-6D, allowing derivation of quality-adjusted life-years. As a pilot, our study was not powered to identify significant differences in outcomes. Qualitatively, we observed that within COs, CFs can be formally recognised as rehabilitative but in practice can be seen as punitive. Limitations Changes in probation presented many challenges that limited recruitment and collection of cost data. Conclusions Recruitment is likely to be feasible in a more stable probation environment. Retention among probationers is challenging but assessing reconvictions from existing data is feasible. We found worse health and risk of reoffending among offenders at CFs, reflecting the use of CFs by probation to manage challenging offenders. Future work A sufficiently powered natural experiment is feasible and of value. Using reconvictions (from police data) as a primary outcome is one solution to challenges with retention. Propensity analysis provides a viable method for comparison despite differences in participants at CFs and comparator sites. However, future work is dependent on stability and support for CFs within probation services. Study registration This study is registered as PROSPERO CRD42014013892 and SW2013–04 (the Campbell Collaboration). Funding details The National Institute for Health Research Public Health Research programme.

Factors Associated with Birth Location among Reproductive Age Women in Ghana: A Cross-Sectional Survey

Abstract: Maternal mortality remains a major public health challenge in Ghana and among African countries, despite several policy measures adopted by the international community and national governments. While the location of delivery plays a key role in contributing to maternal deaths, several factors influence the decision to either deliver at home or in a health facility. This study examined factors associated with the choice of site of delivery in the Asunafo South District of the Brong Ahafo Region, Ghana. A cross-sectional survey of 138 women aged 18 years and or above were interviewed using a structured questionnaire. Association between predictors and the place of delivery was analysed using chi-square test (𝜒2) at 95% confidence interval. Factors with 𝑃 value < 0.05 were considered statistically significant. The results indicate that 52.2% of the women interviewed delivered at home as against 47.8% who gave birth at a health facility. Maternal age (p<0.003), marital status (p<0.001), level of education (p<0.004) and occupation (p<0.001) were found to be statistically significant to influence place of delivery. Other associated factors with birth location include traditional belief systems, convenience, cost and access to health services. The paper concludes that there should be extensive health education by all stakeholders including the Ghana Health Service, Ministry of Health regarding the benefits skilled birth attendants’ services bring to maternal health outcomes.

Knowledge of Food Safety and Practices among Cooked Food Vendors in the East Mamprusi District of the Northern Region of Ghana

Abstract: Food safety has become a major public health concern globally as street food vending is a rapidly growing industry in both developed and the developing world. An increasing incidence of diarrhoea cases in Ghana is attributable to unhygienic street food vending. This study was carried out to assess knowledge and practices regarding food safety among cooked food vendors. The research design was a cross-sectional study. A sample size of 81 food vendors was selected. Data was collected using questionnaire. Results showed that 98.9% of the respondents were females. Majority of the food vendors had some knowledge on food safety and hygiene and knew that diarrheal diseases could result from food contamination and/or poisoning. 98% of the respondents said hand washing was necessary at all times but, only 13.6% washed their hands all the time and out of this only 45.5% washed their hands always with soap and running water. Only 21% store leftover foods in the refrigerator whilst 41% store food at room temperature. 35% of the respondents had undergone medical screening for food vendors and out of this percentage, 60% were screened more than six months ago. It was concluded that food vendors in East Mamprusi generally had a fair knowledge of food safety and hygiene but the practice of food hygiene was inadequate. Thus there is the need for health officials and the local government to periodically inspect and encourage food vendors to practice food hygiene and to always to be available for medical screening periodically.

Willingness to Teach, Perform and Other Views about Bystander Cardiopulmonary Resuscitation among Nigerian University Students Following Conventional and Hands-only Training Techniques

Abstract: Introduction: The bystander CPR training techniques (methods) could influence the willingness of participants to teach others CPR, perform it on victims of out-of-hospital cardiac arrest (OHCA) and their other general views about bystander CPR. This study aimed at comparing two cohorts of Nigerian undergraduate students’ willingness to teach others bystander CPR after training one group on hands-only CPR and the other on conventional CPR; their willingness to carry out bystander CPR after the trainings; and their other views about bystander CPR after the trainings. Materials and Method: Two cohorts of University undergraduate students (70 participants in each group) were trained on bystander CPR – one group on hands-only CPR and the other on conventional CPR. The two groups were randomly selected from the study population. After the trainings, they were served the same self-administered questionnaire on bystander CPR which they filled in during the pre-training stage. The data was analysed using descriptive statistics and analysis of variance (ANOVA) with the P-value set at P < 0.05. Results: 100% of the participants in both hands-only and conventional CPR training groups were willing to teach others CPR after the trainings with high percentages of the participants willing to perform it on different victims. Their overall willingness to teach bystander, perform it on victims and their other general views about bystander CPR were impressive and statistically the same in the two groups (P < 0.05), except in one item. Conclusion: The type of bystander CPR training technique did not significantly influence the participants’ willingness to teach and perform bystander CPR and most of their other views about bystander CPR.