Systematic reviews of health effects of social interventions: 2. Best available evidence: how low should you go?

Advancing Evidence-Based Public Health Policy: How Core Component Thinking Can Illuminate the Multilevel Nature of Public Health Policy

A growing body of literature uses the concept of core components to better understand small-scale programmatic interventions. Instead of interventions being viewed as unitary "black boxes," interventions are viewed as configurations of core components, which are the parts of interventions that carry their causal potential and therefore need to be reproduced with fidelity to produce the intended effect. To date, the concept of core components has not been as widely applied to public health policy interventions as it has to programmatic interventions. The purpose of this topical review is to familiarize public health practitioners and policy makers with the concept of core components as applied to public health policy interventions. Raising the profile of core component thinking can foster mindful adaptation and implementation of public health policy interventions while encouraging further research to enhance the supporting evidence base. We present 3 types of multilevel interactions in which the core components of a public health policy intervention produce effects at the population level by (1) seeking to directly affect individual behavior, (2) facilitating adoption of programmatic interventions by intermediaries, and (3) encouraging intermediaries to take action that can shape changes in upstream drivers of population health. Changing the unit of analysis from whole policies to core components can provide a basis for understanding how policies work and for facilitating novel evidence-generating strategies and rapid evidence reviews that can inform future adaptation efforts.

The co-benefits of active travel interventions beyond physical activity: a systematic review

Active travel is a widely recognised strategy for promoting active living but its co-benefits beyond increasing physical activity, such as broader health, environmental, and social benefits, have rarely been synthesised. We conducted a systematic review to examine the co-benefits of active travel interventions. Following a preregistered protocol (PROSPERO CRD42022359059), we identified 80 studies for the search period from Jan 1, 2000, to Sept 13, 2022. Across studies, there was consistent evidence that active travel interventions offered co-benefits beyond physical activity. Particularly, 25 (71%) of 35 studies favoured improved safety outcomes, 20 (67%) of 30 showed improved health, 17 (85%) of 20 supported economic benefits, 16 (84%) of 19 highlighted improved transport quality, 12 (92%) of 13 showed environmental benefits, and four (80%) of five documented social benefits. Despite the overall low-certainty evidence, mostly limited by the quasi-experimental design and natural-experimental design of many of the studies, active travel interventions offer unique opportunities to engage stakeholders across sectors to jointly address major societal issues, such as physical inactivity, traffic safety, and carbon emissions. This evidence can inform the design, implementation, and evaluation of active travel interventions.

What is safety leadership? A systematic review of definitions

INTRODUCTION

To the authors' knowledge, no systematic review has examined the definition of safety leadership in the academic literature to date. A review was therefore carried out to determine how safety leadership was defined in the peer reviewed empirical literature and thematic analysis was employed to identify patterned meanings across the data.

METHOD

Thirty-seven primary definitions, or definitions that were not borrowed from other studies, were identified. Of these 37, seven conceptual definitions were found to be evidence-based, six of which were endorsed by their operational counterpart definitions and one which was derived using exploratory research.

RESULTS

These seven definitions showed strong alignment with the three themes that emerged from the thematic analysis that capture the why, how, and who of safety leadership. Transformational leadership theory formed the foundation for many of the definitions in the academic literature, despite recent evidence suggesting that adopting multiple forms of leadership styles would be more effective for improving workplace safety.

PRACTICAL APPLICATIONS

Gaps in the current evidence base are explored and suggestions for future research are discussed.

Assessing the effects of population-level political, economic and social exposures, interventions and policies on inclusive economy outcomes for health equity in high-income countries: a systematic review of reviews

BACKGROUND

A fairer economy is increasingly recognised as crucial for tackling widening social, economic and health inequalities within society. However, which actions have been evaluated for their impact on inclusive economy outcomes is yet unknown.

OBJECTIVE

Identify the effects of political, economic and social exposures, interventions and policies on inclusive economy (IE) outcomes in high-income countries, by systematically reviewing the review-level evidence.

METHODS

We conducted a review of reviews; searching databases (May 2020) EconLit, Web of Science, Sociological Abstracts, ASSIA, International Bibliography of the Social Sciences, Public Health Database, Embase and MEDLINE; and registries PROSPERO, Campbell Collaboration and EPPI Centre (February 2021) and grey literature (August/September 2020). We aimed to identify reviews which examined social, political and/or economic exposures, interventions and policies in relation to two IE outcome domains: (i) equitable distribution of the benefits of the economy and (ii) equitable access to the resources needed to participate in the economy. Reviews had to include primary studies which compared IE outcomes within or between groups. Quality was assessed using a modified version of AMSTAR-2 and data synthesised informed by SWiM principles.

RESULTS

We identified 19 reviews for inclusion, most of which were low quality, as was the underlying primary evidence. Most reviews (n = 14) had outcomes relating to the benefits of the economy (rather than access to resources) and examined a limited set of interventions, primarily active labour market programmes and social security. There was limited high-quality review evidence to draw upon to identify effects on IE outcomes. Most reviews focused on disadvantaged groups and did not consider equity impacts.

CONCLUSIONS

Review-level evidence is sparse and focuses on 'corrective' approaches. Future reviews should examine a diverse set of 'upstream' actions intended to be inclusive 'by design' and consider a wider range of outcomes, with particular attention to socioeconomic inequalities.

Using administrative data to evaluate national policy impacts on child and maternal health: a research framework from the Maternal and Child Health Network (MatCHNet)

Reducing health inequalities by addressing the social circumstances in which children are conceived and raised is a societal priority. Early interventions are key to improving outcomes in childhood and long-term into adulthood. Across the UK nations, there is strong political commitment to invest in the early years. National policy interventions aim to tackle health inequalities and deliver health equity for all children. Evidence to determine the effectiveness of socio-structural policies on child health outcomes is especially pressing given the current social and economic challenges facing policy-makers and families with children. As an alternative to clinical trials or evaluating local interventions, we propose a research framework that supports evaluating the impact of whole country policies on child health outcomes. Three key research challenges must be addressed to enable such evaluations and improve policy for child health: (1) policy prioritisation, (2) identification of comparable data and (3) application of robust methods.

Identifying opportunities for upstream evaluations relevant to child and maternal health: a UK policy-mapping review

OBJECTIVE

Interventions to tackle the social determinants of health can improve outcomes during pregnancy and early childhood, leading to better health across the life course. Variation in content, timing and implementation of policies across the 4 UK nations allows for evaluation. We conducted a policy-mapping review (1981-2021) to identify relevant UK early years policies across the social determinants of health framework, and determine suitable candidates for evaluation using administrative data.

METHODS

We used open keyword and category searches of UK and devolved Government websites, and hand searched policy reviews. Policies were rated and included using five criteria: (1) Potential for policy to affect maternal and child health outcomes; (2) Implementation variation across the UK; (3) Population reach and expected effect size; (4) Ability to identify exposed/eligible group in administrative data; (5) Potential to affect health inequalities. An expert consensus workshop determined a final shortlist.

RESULTS

336 policies and 306 strategy documents were identified. Policies were mainly excluded due to criteria 2-4, leaving 88. The consensus workshop identified three policy areas as suitable candidates for natural experiment evaluation using administrative data: pregnancy grants, early years education and childcare, and Universal Credit.

CONCLUSION

Our comprehensive policy review identifies valuable opportunities to evaluate sociostructural impacts on mother and child outcomes. However, many potentially impactful policies were excluded. This may lead to the inverse evidence law, where there is least evidence for policies believed to be most effective. This could be ameliorated by better access to administrative data, staged implementation of future policies or alternative evaluation methods.

Policy actors' perceptions of public participation to tackle health inequalities in Scotland: a paradox?

BACKGROUND

Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities.

METHODS

In 2019-2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking.

RESULTS

Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges.

CONCLUSIONS

Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities.

Healthy Community Design, Anti-displacement, and Equity Strategies in the USA: A Scoping Review

Recent investments in built environment infrastructure to create healthy communities have highlighted the need for equity and environmental justice. Although the benefits of healthy community design (e.g., connecting transportation systems and land use changes) are well established, some reports suggest that these changes may increase property values. These increases can raise the risk of displacement for people with low incomes and/or who are from racial and ethnic minority groups, who would then miss out on benefits from changes in community design. This review scanned the literature for displacement mitigation and prevention measures, with the goal of providing a compilation of available strategies for a wide range of audiences including public health practitioners. A CDC librarian searched the Medline, EbscoHost, Scopus, and ProQuest Central databases, and we identified grey literature using Google and Google Scholar searches. The indexed literature search identified 6 articles, and the grey literature scan added 18 articles. From these 24 total articles, we identified 141 mitigation and prevention strategies for displacement and thematically characterized each by domain using an adapted existing typology. This work provides a well-categorized inventory for practitioners and sets the stage for future evaluation research on the implementation of strategies and practices to reduce displacement.

Eliciting public values on health inequalities: missing evidence for policy windows?

BACKGROUND

There is a widening health divide in the UK despite health inequalities being a long-standing subject of policy and research. New types of evidence are needed.

KEY POINTS FOR DISCUSSION

Knowledge of public values for non-health policies and their associated (non-)health outcomes is currently missing from decision-making processes. Eliciting public values using stated preference techniques can provide insights on what the general public would be willing to give-up for different distributions of (non-)health outcomes and the policies that can achieve them. To understand the role this evidence could have in decision-making processes, Kingdon's multiple streams analysis (MSA) is used as a policy lens to explore how evidence of public values could affect policy processes for ways to tackle health inequalities.

CONCLUSIONS AND IMPLICATIONS

This paper outlines how evidence of public values could be elicited through the use of stated preference techniques and suggests this could facilitate the creation of policy windows for tackling health inequalities. Additionally, Kingdon's MSA helps make explicit six cross-cutting issues when generating this new form of evidence. This suggests the need to explore reasons for public values and how decision-makers would use such evidence. With an awareness of these issues, evidence on public values has the potential to support upstream policies to tackle health inequalities.

A Tailored Approach: A model for literature searching in complex systematic reviews

Our previous work identified that nine leading guidance documents for seven different types of systematic review advocated the same process of literature searching. We defined and illustrated this process and we named it ‘the Conventional Approach’. The Conventional Approach appears to meet the needs of researchers undertaking literature searches for systematic reviews of clinical interventions. In this article, we report a new and alternate process model of literature searching called ‘A Tailored Approach’. A Tailored Approach is indicated as a search process for complex reviews which do not focus on the evaluation of clinical interventions. The aims of this article are to (1) explain the rationale for, and the theories behind, the design of A Tailored Approach; (2) report the current conceptual illustration of A Tailored Approach and to describe a user’s interaction with the process model; and (3) situate the elements novel to A Tailored Approach (when compared with the Conventional Approach) in the relevant literature. A Tailored Approach suggests investing time at the start of a review, to develop the information needs from the research objectives, and to tailor the search approach to studies or data. Tailored Approaches should be led by the information specialist (librarian) but developed by the research team. The aim is not necessarily to focus on comprehensive retrieval. Further research is indicated to evaluate the use of supplementary search methods, methods of team-working to define search approaches, and to evaluate the use of conceptual models of information retrieval for testing and evaluation.

Identifying evidence for five realist reviews in primary health care: A comparison of search methods

The approach to identifying evidence for inclusion in realist reviews differs from that used in 'traditional' systematic reviews. Guidance suggests that realist reviews should be inclusive of diverse data from a range of sources, gathered in iterative searching cycles. Saturation is prioritised over exhaustiveness. Supplementary techniques such as citation snowballing are emphasised as potentially important sources of evidence. This paper describes the processes used to identify evidence in a selection of realist reviews focused on primary health care settings and examines the origin and type of evidence selected for inclusion. Data from five realist reviews were extracted from (a) reviewers' reference management libraries and (b) records kept by review teams. Although all reviews focused on primary health care, they used data from a wide range of document types and research designs, drawing on learning from multiple perspectives and settings, and sourced the documents containing this data in a variety of ways. Systematic searching of academic databases played an important role, supplementary search techniques such as snowballing were used to identify a significant proportion of documents included in the reviews. Our analysis demonstrates the diverse data sources used within realist reviews and the need for flexible, responsive efforts to identify relevant documents. Reviewers and information specialists should devise approaches to data gathering that reflect the individual needs of realist review projects and report these transparently.

Decision-making for active living infrastructure in new communities: a qualitative study in England

BACKGROUND

Urban design can influence population levels of physical activity and subsequent health impacts. This qualitative study investigates local level decision-making for 'active living' infrastructure (ALI)-walking and cycling infrastructure and open spaces in new communities.

METHODS

Thirty-five semi-structured interviews with stakeholders, and limited ethnographic observations, were conducted with local government and private sector stakeholders including urban and transport planners, public health practitioners, elected councillors and developers. Interview transcripts were coded and analysed thematically.

RESULTS

Public health practitioners in local government could act as knowledge brokers and leaders to motivate non-health stakeholders such as urban and transport planners to consider health when designing and building new communities. They needed to engage at the earliest stages and be adequately resourced to build relationships across sectors, supporting non-health outcomes such as tackling congestion, which often had greater political traction. 'Evidence' for decision-making identified problems (going beyond health), informed solutions, and also justified decisions post hoc, although case study examples were not always convincing if not considered contextually relevant.

CONCLUSION

We have developed a conceptual model with three factors needed to bridge the gap between evidence and ALI being built: influential public health practitioners; supportive policies in non-health sectors; and adequate resources.

A Perspective for Understanding Trauma and the Criminal Juvenile Justice System: Using a Trauma-Informed Lens for Meaningful and Sustained Change

Trauma exposure and posttraumatic stress disorder are common and are associated with a wide range of negative psychiatric and physical outcomes. Furthermore, a large percentage of justice-involved youth have high rates of trauma exposure and trauma-related symptoms. Addressing these issues would improve outcomes at the level of the justice system overall and in the lives of justice-involved youth. Nonetheless, awareness, education, and implementation of trauma-informed approaches in the criminal juvenile justice system are lacking. This article explores current literature that operationalizes trauma-informed practices and approaches in the criminal and juvenile justice systems. Unfortunately, there is no shared understanding or definition of trauma and no predictability in trauma-informed practices and approaches in the criminal juvenile justice system. Despite the presence of written policies, the application and execution of such policies are limited and inconsistent throughout the system. These limitations contribute to ongoing, systemic institutional racism, lack of mental health or substance abuse treatment, limited diversion options, and unnecessary jail and prison sentences, which together amplify financial and humanitarian costs. We argue that in order for the criminal juvenile justice system to become trauma-informed, it should (1) meet basic needs of clients, (2) check and change narratives, and check underlying assumptions, (3) focus on skill building/habilitation, (4) move away from punishment and toward rehabilitation and humanitarian approaches, and (5) heal and support members that work in and for the system. We conclude that there is a need to improve processes for education, training, and coaching in, and consistent application of, trauma-informed practices and approaches within the criminal and juvenile justice systems.

Use and value of systematic reviews in English local authority public health: a qualitative study

Background

Responsibility for public health in England transferred from the National Health Service to local authorities in 2013, representing a different decision-making environment. Systematic reviews are considered the gold standard of evidence for clinical decision-making but little is known about their use in local government public health. This study aimed to explore the extent to which public health decision-makers in local authorities engage with systematic reviews and how they do so.

Methods

Semi-structured interviews were conducted with senior public health practitioners (n = 14) in Yorkshire and the Humber local authorities. Sampling was purposive and involved contacting Directors of Public Health directly and snowballing through key contacts. Face-to-face or telephone interviews were digitally recorded, transcribed verbatim and analysed using the Framework Method.

Results

Public health practitioners described using systematic reviews directly in decision-making and engaging with them more widely in a range of ways, often through a personal commitment to professional development. They saw themselves as having a role to advocate for the use of rigorous evidence, including systematic reviews, in the wider local authority. Systematic reviews were highly valued in principle and public health practitioners had relevant skills to find and appraise them. However, the extent of use varied by individual and local authority and was limited by the complexity of decision-making and various barriers. Barriers included that there were a limited number of systematic reviews available on certain public health topics, such as the wider determinants of health, and that the narrow focus of reviews was not reflective of complex public health decisions facing local authorities. Reviews were used alongside a range of other evidence types, including grey literature. The source of evidence was often considered an indicator of quality, with specific organisations, such as Public Health England, NICE and Cochrane, particularly trusted.

Conclusions

Research use varies and should be considered within the specific decision-making and political context. There is a need for systematic reviews to be more reflective of the decisions facing local authority public health teams.

Using natural experimental studies to guide public health action: turning the evidence-based medicine paradigm on its head

Despite smaller effect sizes, interventions delivered at population level to prevent non-communicable diseases generally have greater reach, impact and equity than those delivered to high-risk groups. Nevertheless, how to shift population behaviour patterns in this way remains one of the greatest uncertainties for research and policy. Evidence about behaviour change interventions that are easier to evaluate tends to overshadow that for population-wide and system-wide approaches that generate and sustain healthier behaviours. Population health interventions are often implemented as natural experiments, which makes their evaluation more complex and unpredictable than a typical randomised controlled trial (RCT). We discuss the growing importance of evaluating natural experiments and their distinctive contribution to the evidence for public health policy. We contrast the established evidence-based practice pathway, in which RCTs generate 'definitive' evidence for particular interventions, with a practice-based evidence pathway in which evaluation can help adjust the compass bearing of existing policy. We propose that intervention studies should focus on reducing critical uncertainties, that non-randomised study designs should be embraced rather than tolerated and that a more nuanced approach to appraising the utility of diverse types of evidence is required. The complex evidence needed to guide public health action is not necessarily the same as that which is needed to provide an unbiased effect size estimate. The practice-based evidence pathway is neither inferior nor merely the best available when all else fails. It is often the only way to generate meaningful evidence to address critical questions about investing in population health interventions.

Social Interventions Targeting Social Relations Among Older People at Nursing Homes: A Qualitative Synthesized Systematic Review

Social relations are part of the complex set of factors affecting health and well-being in old age. This systematic review seeks to uncover whether social interventions have an effect on social and health-related measures among nursing home residents. The authors screened PubMed, Scopus, and PsycINFO for relevant peer-reviewed literature. Interventions were included if (1) they focused primarily on social relations or related terms such as loneliness, social support, social isolation, social network, or being involuntarily alone either as the base theory of the intervention or as an outcome measure of the intervention; (2) they were implemented at nursing homes (or similar setting); (3) they had a narrative activity as its core (as opposed to dancing, gardening or other physical activity); (4) their participants met either physically or nonphysically, ie, via video-conference or the like; and if (5) they targeted residents at a nursing home. The authors systematically appraised the quality of the final selection of studies using the Mixed Methods Assessments Tool (MMAT) version 2011 and did a qualitative synthesis of the final study selection. A total of 10 studies were included. Reminiscence therapy was the most common intervention. Studies also included video-conference, cognitive, and support group interventions. All studies found the social interventions brought about positive trends on either/or the social and health-related measures included. Despite limited and very diverse evidence, our systematic review indicated a positive social and health-related potential of social interventions for older people living in nursing homes or similar institutions.

Title: Can changing the physical environment promote walking and cycling? A systematic review of what works and how

Environmental changes aimed at encouraging walking or cycling may promote activity and improve health, but evidence suggests small or inconsistent effects in practice. Understanding how an intervention works might help explain the effects observed and provide guidance about generalisability. We therefore aimed to review the literature on the effects of this type of intervention and to understand how and why these may or may not be effective. We searched eight electronic databases for existing systematic reviews and mined these for evaluative studies of physical environmental changes and assessed changes in walking, cycling or physical activity. We then searched for related sources including quantitative or qualitative studies, policy documents or reports. We extracted information on the evidence for effects ('estimation'), contexts and mechanisms ('explanation') and assessed credibility, and synthesised material narratively. We identified 13 evaluations of interventions specifically targeting walking and cycling and used 46 related sources. 70% (n = 9 evaluations) scored 3 or less on the credibility criteria for effectiveness. 6 reported significant positive effects, but higher quality evaluations were more likely to report positive effects. Only two studies provided rich evidence of mechanisms. We identified three common resources that interventions provide to promote walking and cycling: (i) improving accessibility and connectivity; (ii) improving traffic and personal safety; and (iii) improving the experience of walking and cycling. The most effective interventions appeared to target accessibility and safety in both supportive and unsupportive contexts. Although the evidence base was relatively limited, we were able to understand the role of context in the success of interventions. Researchers and policy makers should consider the context and mechanisms which might operate before evaluating and implementing interventions.

Searching for qualitative health research required several databases and alternative search strategies: a study of coverage in bibliographic databases

OBJECTIVE

Retrieving the qualitative literature can be challenging, but the number and specific choice of databases are key factors. The aim of the present study is to provide guidance for the choice of databases for retrieving qualitative health research.

STUDY DESIGN AND SETTING

Seventy-one qualitative systematic reviews, from the Cochrane Database of Systematic Reviews and JBI database of Systematic Reviews and Implementation Reports, including 927 qualitative studies, were used to analyze the coverage of the qualitative literature in nine bibliographic databases.

RESULTS

The results show that 94.4% of the qualitative studies are indexed in at least one database, with a lower coverage for publication types other than journal articles. Maximum recall with two databases is 89.1%, with three databases recall increases to 92% and maximum recall with four databases is 93.1%. The remaining 6.9% of the publications consists of 1.3% scattered across five databases and 5.6% that are not indexed in any of the nine databases used in this study.

CONCLUSION

Retrieval in one or a few-although well selected-databases does not provide all the relevant qualitative studies. The remaining studies needs to be located using several other databases and alternative search strategies.

Considerations of complexity in rating certainty of evidence in systematic reviews: a primer on using the GRADE approach in global health

Public health interventions and health technologies are commonly described as 'complex', as they involve multiple interacting components and outcomes, and their effects are largely influenced by contextual interactions and system-level processes. Systematic reviewers and guideline developers evaluating the effects of these complex interventions and technologies report difficulties in using existing methods and frameworks, such as the Grading of Recommendations Assessment, Development and Evaluation (GRADE). As part of a special series of papers on implications of complexity in the WHO guideline development, this paper serves as a primer on how to consider sources of complexity when using the GRADE approach to rate certainty of evidence. Relevant sources of complexity in systematic reviews, health technology assessments and guidelines of public health are outlined and mapped onto the reported difficulties in rating the estimates of the effect of these interventions. Recommendations on how to address these difficulties are further outlined, and the need for an integrated use of GRADE from the beginning of the review or guideline development is emphasised. The content of this paper is informed by the existing GRADE guidance, an ongoing research project on considering sources of complexity when applying the GRADE approach to rate certainty of evidence in systematic reviews and the review authors' own experiences with using GRADE.

Who knows best? A Q methodology study to explore perspectives of professional stakeholders and community participants on health in low-income communities

Background

Health inequalities in the UK have proved to be stubborn, and health gaps between best and worst-off are widening. While there is growing understanding of how the main causes of poor health are perceived among different stakeholders, similar insight is lacking regarding what solutions should be prioritised. Furthermore, we do not know the relationship between perceived causes and solutions to health inequalities, whether there is agreement between professional stakeholders and people living in low-income communities or agreement within these groups.

Methods

Q methodology was used to identify and describe the shared perspectives (‘subjectivities’) that exist on i) why health is worse in low-income communities (‘Causes’) and ii) the ways that health could be improved in these same communities (‘Solutions’).

Purposively selected individuals (n = 53) from low-income communities (n = 25) and professional stakeholder groups (n = 28) ranked ordered sets of statements – 34 ‘Causes’ and 39 ‘Solutions’ – onto quasi-normal shaped grids according to their point of view. Factor analysis was used to identify shared points of view. ‘Causes’ and ‘Solutions’ were analysed independently, before examining correlations between perspectives on causes and perspectives on solutions.

Results

Analysis produced three factor solutions for both the ‘Causes’ and ‘Solutions’. Broadly summarised these accounts for ‘Causes’ are: i) ‘Unfair Society’, ii) ‘Dependent, workless and lazy’, iii) ‘Intergenerational hardships’ and for ‘Solutions’: i) ‘Empower communities’, ii) ‘Paternalism’, iii) ‘Redistribution’. No professionals defined (i.e. had a significant association with one factor only) the ‘Causes’ factor ‘Dependent, workless and lazy’ and the ‘Solutions’ factor ‘Paternalism’. No community participants defined the ‘Solutions’ factor ‘Redistribution’. The direction of correlations between the two sets of factor solutions – ‘Causes’ and ‘Solutions’ – appear to be intuitive, given the accounts identified.

Conclusions

Despite the plurality of views there was broad agreement across accounts about issues relating to money. This is important as it points a way forward for tackling health inequalities, highlighting areas for policy and future research to focus on.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3884-9) contains supplementary material, which is available to authorized users.

Choosing Channels, Sources, and Content for Communicating Prostate Cancer Information to Black Men: A Systematic Review of the Literature

The purpose of this study was to identify effective channels, sources, and content approaches for communicating prostate cancer prevention information to Black men. The Web of Science, PubMed and GoogleScholar databases, as well as reviews of reference lists for selected publications, were searched to select articles relevant to cancer communication channels, sources or content for Black men, focused on male-prevalent cancers and published in English. Articles were excluded if they examined only patient–provider communication, dealt exclusively with prostate cancer patients or did not separate findings by race. The selection procedures identified 41 relevant articles, which were systematically and independently reviewed by two team members to extract data on preferred channels, sources, and content for prostate cancer information. This review revealed that Black men prefer interpersonal communication for prostate cancer information; however, video can be effective. Trusted sources included personal physicians, clergy, and other community leaders, family (especially spouses) and prostate cancer survivors. Men want comprehensive information about screening, symptoms, treatment, and outcomes. Messages should be culturally tailored, encouraging empowerment and “ownership” of disease. Black men are open to prostate cancer prevention information through mediated channels when contextualized within spiritual/cultural beliefs and delivered by trusted sources.

Challenges Facing Evidence-Based Prevention: Incorporating an Abductive Theory of Method

Current systems used to determine whether prevention programs are "evidence-based" rely on the logic of deductive reasoning. This reliance has fostered implementation of strategies with explicitly stated evaluation criteria used to gauge program validity and suitability for dissemination. Frequently, investigators resort to the randomized controlled trial (RCT) combined with null hypothesis significance testing (NHST) as a means to rule out competing hypotheses and determine whether an intervention works. The RCT design has achieved success across numerous disciplines but is not without limitations. We outline several issues that question allegiance to the RCT, NHST, and the hypothetico-deductive method of scientific inquiry. We also discuss three challenges to the status of program evaluation including reproducibility, generalizability, and credibility of findings. As an alternative, we posit that extending current program evaluation criteria with principles drawn from an abductive theory of method (ATOM) can strengthen our ability to address these challenges and advance studies of drug prevention. Abductive reasoning involves working from observed phenomena to the generation of alternative explanations for the phenomena and comparing the alternatives to select the best possible explanation. We conclude that an ATOM can help increase the influence and impact of evidence-based prevention for population benefit.

Building Capacity for Evidence-Based Public Health: Reconciling the Pulls of Practice and the Push of Research

Timely implementation of principles of evidence-based public health (EBPH) is critical for bridging the gap between discovery of new knowledge and its application. Public health organizations need sufficient capacity (the availability of resources, structures, and workforce to plan, deliver, and evaluate the preventive dose of an evidence-based intervention) to move science to practice. We review principles of EBPH, the importance of capacity building to advance evidence-based approaches, promising approaches for capacity building, and future areas for research and practice. Although there is general agreement among practitioners and scientists on the importance of EBPH, there is less clarity on the definition of evidence, how to find it, and how, when, and where to use it. Capacity for EBPH is needed among both individuals and organizations. Capacity can be strengthened via training, use of tools, technical assistance, assessment and feedback, peer networking, and incentives. Modest investments in EBPH capacity building will foster more effective public health practice.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

BACKGROUND

Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents.

OBJECTIVES

To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health.

DATA COLLECTION AND ANALYSIS

One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3).

MAIN RESULTS

Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems.

AUTHORS' CONCLUSIONS

The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

A comparison of results of empirical studies of supplementary search techniques and recommendations in review methodology handbooks: a methodological review

BACKGROUND

The purpose and contribution of supplementary search methods in systematic reviews is increasingly acknowledged. Numerous studies have demonstrated their potential in identifying studies or study data that would have been missed by bibliographic database searching alone. What is less certain is how supplementary search methods actually work, how they are applied, and the consequent advantages, disadvantages and resource implications of each search method. The aim of this study is to compare current practice in using supplementary search methods with methodological guidance.

METHODS

Four methodological handbooks in informing systematic review practice in the UK were read and audited to establish current methodological guidance. Studies evaluating the use of supplementary search methods were identified by searching five bibliographic databases. Studies were included if they (1) reported practical application of a supplementary search method (descriptive) or (2) examined the utility of a supplementary search method (analytical) or (3) identified/explored factors that impact on the utility of a supplementary method, when applied in practice.

RESULTS

Thirty-five studies were included in this review in addition to the four methodological handbooks. Studies were published between 1989 and 2016, and dates of publication of the handbooks ranged from 1994 to 2014. Five supplementary search methods were reviewed: contacting study authors, citation chasing, handsearching, searching trial registers and web searching.

CONCLUSIONS

There is reasonable consistency between recommended best practice (handbooks) and current practice (methodological studies) as it relates to the application of supplementary search methods. The methodological studies provide useful information on the effectiveness of the supplementary search methods, often seeking to evaluate aspects of the method to improve effectiveness or efficiency. In this way, the studies advance the understanding of the supplementary search methods. Further research is required, however, so that a rational choice can be made about which supplementary search strategies should be used, and when.

From Delivery to Adoption of Physical Activity Guidelines: Realist Synthesis

BACKGROUND

Evidence-based guidelines published by health authorities for the promotion of health-enhancing physical activity (PA), continue to be implemented unsuccessfully and demonstrate a gap between evidence and policies. This review synthesizes evidence on factors influencing delivery, adoption and implementation of PA promotion guidelines within different policy sectors (e.g., health, transport, urban planning, sport, education).

METHODS

Published literature was initially searched using PubMed, EBSCO, Google Scholar and continued through an iterative snowball technique. The literature review spanned the period 2002-2017. The realist synthesis approach was adopted to review the content of 39 included studies. An initial programme theory with a four-step chain from evidence emersion to implementation of guidelines was tested.

RESULTS

The synthesis furthers our understanding of the link between PA guidelines delivery and the actions of professionals responsible for implementation within health services, school departments and municipalities. The main mechanisms identified for guidance implementation were scientific legitimation, enforcement, feasibility, familiarity with concepts and PA habits. Threats emerged to the successful implementation of PA guidelines at national/local jurisdictional levels.

CONCLUSIONS

The way PA guidelines are developed may influence their adoption by policy-makers and professionals. Useful lessons emerged that may inform synergies between policymaking and professional practices, promoting win-win multisectoral strategies.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children

BACKGROUND

Lone parents in high-income countries have high rates of poverty (including in-work poverty) and poor health. Employment requirements for these parents are increasingly common. 'Welfare-to-work' (WtW) interventions involving financial sanctions and incentives, training, childcare subsidies and lifetime limits on benefit receipt have been used to support or mandate employment among lone parents. These and other interventions that affect employment and income may also affect people's health, and it is important to understand the available evidence on these effects in lone parents.

OBJECTIVES

To assess the effects of WtW interventions on mental and physical health in lone parents and their children living in high-income countries. The secondary objective is to assess the effects of welfare-to-work interventions on employment and income.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, PsycINFO EBSCO, ERIC EBSCO, SocINDEX EBSCO, CINAHL EBSCO, Econlit EBSCO, Web of Science ISI, Applied Social Sciences Index and Abstracts (ASSIA) via Proquest, International Bibliography of the Social Sciences (IBSS) via ProQuest, Social Services Abstracts via Proquest, Sociological Abstracts via Proquest, Campbell Library, NHS Economic Evaluation Database (NHS EED) (CRD York), Turning Research into Practice (TRIP), OpenGrey and Planex. We also searched bibliographies of included publications and relevant reviews, in addition to many relevant websites. We identified many included publications by handsearching. We performed the searches in 2011, 2013 and April 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of mandatory or voluntary WtW interventions for lone parents in high-income countries, reporting impacts on parental mental health, parental physical health, child mental health or child physical health.

DATA COLLECTION AND ANALYSIS

One review author extracted data using a standardised extraction form, and another checked them. Two authors independently assessed risk of bias and the quality of the evidence. We contacted study authors to obtain measures of variance and conducted meta-analyses where possible. We synthesised data at three time points: 18 to 24 months (T1), 25 to 48 months (T2) and 49 to 72 months (T3).

MAIN RESULTS

Twelve studies involving 27,482 participants met the inclusion criteria. Interventions were either mandatory or voluntary and included up to 10 discrete components in varying combinations. All but one study took place in North America. Although we searched for parental health outcomes, the vast majority of the sample in all included studies were female. Therefore, we describe adult health outcomes as 'maternal' throughout the results section. We downgraded the quality of all evidence at least one level because outcome assessors were not blinded. Follow-up ranged from 18 months to six years. The effects of welfare-to-work interventions on health were generally positive but of a magnitude unlikely to have any tangible effects.At T1 there was moderate-quality evidence of a very small negative impact on maternal mental health (standardised mean difference (SMD) 0.07, 95% Confidence Interval (CI) 0.00 to 0.14; N = 3352; studies = 2)); at T2, moderate-quality evidence of no effect (SMD 0.00, 95% CI 0.05 to 0.05; N = 7091; studies = 3); and at T3, low-quality evidence of a very small positive effect (SMD -0.07, 95% CI -0.15 to 0.00; N = 8873; studies = 4). There was evidence of very small positive effects on maternal physical health at T1 (risk ratio (RR) 0.85, 95% CI 0.54 to 1.36; N = 311; 1 study, low quality) and T2 (RR 1.06, 95% CI 0.95 to 1.18; N = 2551; 2 studies, moderate quality), and of a very small negative effect at T3 (RR 0.97, 95% CI 0.91 to 1.04; N = 1854; 1 study, low quality).At T1, there was moderate-quality evidence of a very small negative impact on child mental health (SMD 0.01, 95% CI -0.06 to 0.09; N = 2762; studies = 1); at T2, of a very small positive effect (SMD -0.04, 95% CI -0.08 to 0.01; N = 7560; studies = 5), and at T3, there was low-quality evidence of a very small positive effect (SMD -0.05, 95% CI -0.16 to 0.05; N = 3643; studies = 3). Moderate-quality evidence for effects on child physical health showed a very small negative effect at T1 (SMD -0.05, 95% CI -0.12 to 0.03; N = 2762; studies = 1), a very small positive effect at T2 (SMD 0.07, 95% CI 0.01 to 0.12; N = 7195; studies = 3), and a very small positive effect at T3 (SMD 0.01, 95% CI -0.04 to 0.06; N = 8083; studies = 5). There was some evidence of larger negative effects on health, but this was of low or very low quality.There were small positive effects on employment and income at 18 to 48 months (moderate-quality evidence), but these were largely absent at 49 to 72 months (very low to moderate-quality evidence), often due to control group members moving into work independently. Since the majority of the studies were conducted in North America before the year 2000, generalisabilty may be limited. However, all study sites were similar in that they were high-income countries with developed social welfare systems.

AUTHORS' CONCLUSIONS

The effects of WtW on health are largely of a magnitude that is unlikely to have tangible impacts. Since income and employment are hypothesised to mediate effects on health, it is possible that these negligible health impacts result from the small effects on economic outcomes. Even where employment and income were higher for the lone parents in WtW, poverty was still high for the majority of the lone parents in many of the studies. Perhaps because of this, depression also remained very high for lone parents whether they were in WtW or not. There is a lack of robust evidence on the health effects of WtW for lone parents outside North America.

Multiple Risk Behavior Interventions: Meta-analyses of RCTs

CONTEXT

Multiple risk behaviors are common and associated with developing chronic conditions such as heart disease, cancer, or Type 2 diabetes. A systematic review, meta-analysis, and meta-regression of the effectiveness of multiple risk behavior interventions was conducted.

EVIDENCE ACQUISITION

Six electronic databases including MEDLINE, EMBASE, and PsycINFO were searched to August 2016. RCTs of non-pharmacologic interventions in general adult populations were selected. Studies targeting specific at-risk groups (such as people screened for cardiovascular risk factors or obesity) were excluded. Studies were screened independently. Study characteristics and outcomes were extracted and risk of bias assessed by one researcher and checked by another. The Behaviour Change Wheel and Oxford Implementation Index were used to code intervention content and context.

EVIDENCE SYNTHESIS

Random-effects meta-analyses were conducted. Sixty-nine trials involving 73,873 individuals were included. Interventions mainly comprised education and skills training and were associated with modest improvements in most risk behaviors: increased fruit and vegetable intake (0.31 portions, 95% CI=0.17, 0.45) and physical activity (standardized mean difference, 0.25; 95% CI=0.13, 0.38), and reduced fat intake (standardized mean difference, -0.24; 95% CI=-0.36, -0.12). Although reductions in smoking were found (OR=0.78, 95% CI=0.68, 0.90), they appeared to be negatively associated with improvement in other behaviors (such as diet and physical activity). Preliminary evidence suggests that sequentially changing smoking alongside other risk behaviors was more effective than simultaneous change. But most studies assessed simultaneous rather than sequential change in risk behaviors; therefore, comparisons are sparse. Follow-up period and intervention characteristics impacted effectiveness for some outcomes.

CONCLUSIONS

Interventions comprising education (e.g., providing information about behaviors associated with health risks) and skills training (e.g., teaching skills that equip participants to engage in less risky behavior) and targeting multiple risk behaviors concurrently are associated with small changes in diet and physical activity. Although on average smoking was reduced, it appeared changes in smoking were negatively associated with changes in other behaviors, suggesting it may not be optimal to target smoking simultaneously with other risk behaviors.

Barriers and Facilitators to Integrating Health Service Responses to Intimate Partner Violence in Low- and Middle-Income Countries: A Comparative Health Systems and Service Analysis

This systematic review synthesizes 11 studies of health‐sector responses to intimate partner violence (IPV) in low‐ and middle‐income countries. The services that were most comprehensive and integrated in their responsiveness to IPV were primarily in primary health and antenatal care settings. Findings suggest that the following facilitators are important: availability of clear guidelines, policies, or protocols; management support; intersectoral coordination with clear, accessible on‐site and off‐site referral options; adequate and trained staff with accepting and empathetic attitudes toward survivors of IPV; initial and ongoing training for health workers; and a supportive and supervised environment in which to enact new IPV protocols. A key characteristic of the most integrated responses was the connection or “linkages” between different individual factors. Irrespective of their service entry point, what emerged as crucial was a connected systems‐level response, with all elements implemented in a coordinated manner.

Questioning the application of risk of bias tools in appraising evidence from natural experimental studies: critical reflections on Benton et al., IJBNPA 2016

We recently read the article by Benton et al. which reviewed risk of bias in natural experimental studies investigating the impact of the built environment on physical activity (Benton et al., 2016; Int J Behav Nutr Phys Act 13:107). As a technical exercise in assessing risk of bias to understand study quality, we found the results of this study both interesting and potentially useful. However, it prompted a number of concerns with the use of risk of bias tools for assessing the quality of evidence from studies exploiting natural experiments. As we discuss in this commentary, the rigid application of such tools could have adverse effects on the uptake and use of natural experiments in population health research and practice.

Effectiveness of Operative and Nonoperative Care for Adult Spinal Deformity: Systematic Review of the Literature

STUDY DESIGN

Systematic review.

OBJECTIVE

There is a need for synthesizing data on effectiveness of treatments for patients with adult spinal deformity (ASD) due to its increasing prevalence and health care costs for these patients. The objective of this review was to estimate the effectiveness of surgery versus nonoperative care in patients with ASD.

METHODS

A systematic review of articles in published in English using PubMed between 2005 and 2015. Surgical and nonsurgical series that reported baseline and follow-up health-related quality of life measures of patients with ASD with a minimum 2 years of follow-up were selected. Independent extraction of articles by 2 authors using predefined data fields, including risk of bias assessment.

RESULTS

Surgery significantly reduces disability, pain, and improves patients' quality of life. The average postoperative improvement in Oswestry Disability Index was -19.1 (±9.0), Numerical Rating Scale back pain -4.14 (±1.38), Numerical Rating Scale leg pain -3.36 (±1.33), Short-Form Health Survey 36-SF36-Physical Component score 11.2 (±5.07), and Short-Form Health Survey 36-Mental Component score 9.93 (±4.96). The complication rate ranged from 9.52% to 81.52% (mean = 39.62%), and the need for revision surgery ranged from 1.72% to 40.0% (mean = 15.71%). The best existing evidence about nonoperative care of ASD is provided from observational studies with very high risk of bias. Quantitative analyses of nonsurgical cohorts did not demonstrate significant changes in quality of life of patients after 2 years of observation.

CONCLUSIONS

This data may assist clinicians to counsel patients, as well as to inform health care providers and policymakers about what to expect from the treatment for ASD.

The effect of changing the built environment on physical activity: a quantitative review of the risk of bias in natural experiments

BACKGROUND

Evidence regarding the association of the built environment with physical activity is influencing policy recommendations that advocate changing the built environment to increase population-level physical activity. However, to date there has been no rigorous appraisal of the quality of the evidence on the effects of changing the built environment. The aim of this review was to conduct a thorough quantitative appraisal of the risk of bias present in those natural experiments with the strongest experimental designs for assessing the causal effects of the built environment on physical activity.

METHODS

Eligible studies had to evaluate the effects of changing the built environment on physical activity, include at least one measurement before and one measurement of physical activity after changes in the environment, and have at least one intervention site and non-intervention comparison site. Given the large number of systematic reviews in this area, studies were identified from three exemplar systematic reviews; these were published in the past five years and were selected to provide a range of different built environment interventions. The risk of bias in these studies was analysed using the Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions (ACROBAT-NRSI).

RESULTS

Twelve eligible natural experiments were identified. Risk of bias assessments were conducted for each physical activity outcome from all studies, resulting in a total of fifteen outcomes being analysed. Intervention sites included parks, urban greenways/trails, bicycle lanes, paths, vacant lots, and a senior citizen's centre. All outcomes had an overall critical (n = 12) or serious (n = 3) risk of bias. Domains with the highest risk of bias were confounding (due to inadequate control sites and poor control of confounding variables), measurement of outcomes, and selection of the reported result.

CONCLUSIONS

The present review focused on the strongest natural experiments conducted to date. Given this, the failure of existing studies to adequately control for potential sources of bias highlights the need for more rigorous research to underpin policy recommendations for changing the built environment to increase physical activity. Suggestions are proposed for how future natural experiments in this area can be improved.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

Cycling and Diabetes Prevention: Practice-Based Evidence for Public Health Action

Panter and Ogilvie describe findings that link recreational and commuter cycling with reduced incidence of diabetes.

What interventions increase commuter cycling? A systematic review

OBJECTIVE

To identify interventions that will increase commuter cycling.

SETTING

All settings where commuter cycling might take place.

PARTICIPANTS

Adults (aged 18+) in any country.

INTERVENTIONS

Individual, group or environmental interventions including policies and infrastructure.

PRIMARY AND SECONDARY OUTCOME MEASURES

A wide range of 'changes in commuter cycling' indicators, including frequency of cycling, change in workforce commuting mode, change in commuting population transport mode, use of infrastructure by defined populations and population modal shift.

RESULTS

12 studies from 6 countries (6 from the UK, 2 from Australia, 1 each from Sweden, Ireland, New Zealand and the USA) met the inclusion criteria. Of those, 2 studies were randomised control trials and the remainder preintervention and postintervention studies. The majority of studies (n=7) evaluated individual-based or group-based interventions and the rest environmental interventions. Individual-based or group-based interventions in 6/7 studies were found to increase commuter cycling of which the effect was significant in only 3/6 studies. Environmental interventions, however, had small but positive effects in much larger but more difficult to define populations. Almost all studies had substantial loss to follow-up.

CONCLUSIONS

Despite commuter cycling prevalence varying widely between countries, robust evidence of what interventions will increase commuter cycling in low cycling prevalence nations is sparse. Wider environmental interventions that make cycling conducive appear to reach out to hard to define but larger populations. This could mean that environmental interventions, despite their small positive effects, have greater public health significance than individual-based or group-based measures because those interventions encourage a larger number of people to integrate physical activity into their everyday lives.

Working for the public health: politics, localism and epistemologies of practice

The recent move of public health back to English local government has reignited debates about the role of a medicalised public health profession. The explicit policy rationale for the move was that local government is the arena in which the social determinants of health can be addressed, and that public health specialists could provide neutral evidence to support action on these. However, if a discourse of 'evidence-based' policy is in principle (if not practice) relatively unproblematic within the health arena, within the more overtly politicised local government space, rather different policy imperatives come to the fore. Responding to calls for research on evidence in practice, this article draws on ethnographic data of local authorities in the first year of the reorganised public health function. Focusing on alcohol policy, we explore how decisions that affect public health are rationalised and enacted through discourses of localism, empiricism and holism. These frame policy outcomes as inevitably plural and contingent: a framing which sits uneasily with normative discourses of evidence-based policy. We argue that locating public health in local government necessitates a refocusing of how evidence for public health is conceptualised, to incorporate multiple, and political, understandings of health and wellbeing.

Time to rethink the systematic review catechism? Moving from 'what works' to 'what happens'

Systematic review methods are developing rapidly, and most researchers would recognise their key methodological aspects, such as a closely focussed question, a comprehensive search, and a focus on synthesising 'stronger' rather than 'weaker' evidence. However, it may be helpful to question some of these underlying principles, because while they work well for simpler review questions, they may result in overly narrow approaches to more complex questions and interventions. This commentary discusses some core principles of systematic reviews, and how they may require further rethinking, particularly as reviewers turn their attention to increasingly complex issues, where a Bayesian perspective on evidence synthesis, which would aim to assemble evidence - of different types, if necessary - in order to inform decisions', may be more productive than the 'traditional' systematic review model. Among areas identified for future research are the examination of publication bias in qualitative research; research on the efficiency and potential biases of comprehensive searches in different disciplines; and the use of Bayesian methods in evidence synthesis. The incorporation of a systems perspective into systematic reviews is also an area which needs rapid development.

Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years

BACKGROUND

Undernutrition contributes to five million deaths of children under five each year. Furthermore, throughout the life cycle, undernutrition contributes to increased risk of infection, poor cognitive functioning, chronic disease, and mortality. It is thus important for decision-makers to have evidence about the effectiveness of nutrition interventions for young children.

OBJECTIVES

Primary objective1. To assess the effectiveness of supplementary feeding interventions, alone or with co-intervention, for improving the physical and psychosocial health of disadvantaged children aged three months to five years.Secondary objectives1. To assess the potential of such programmes to reduce socio-economic inequalities in undernutrition.2. To evaluate implementation and to understand how this may impact on outcomes.3. To determine whether there are any adverse effects of supplementary feeding.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, PsycINFO, and seven other databases for all available years up to January 2014. We also searched ClinicalTrials.gov and several sources of grey literature. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that provided supplementary food (with or without co-intervention) to children aged three months to five years, from all countries. Adjunctive treatments, such as nutrition education, were allowed. Controls had to be untreated.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data, and assessed risk of bias. We conducted meta-analyses for continuous data using the mean difference (MD) or the standardised mean difference (SMD) with a 95% confidence interval (CI), correcting for clustering if necessary. We analysed studies from low- and middle-income countries and from high-income countries separately, and RCTs separately from CBAs. We conducted a process evaluation to understand which factors impact on effectiveness.

MAIN RESULTS

We included 32 studies (21 RCTs and 11 CBAs); 26 of these (16 RCTs and 10 CBAs) were in meta-analyses. More than 50% of the RCTs were judged to have low risk of bias for random selection and incomplete outcome assessment. We judged most RCTS to be unclear for allocation concealment, blinding of outcome assessment, and selective outcome reporting. Because children and parents knew that they were given food, we judged blinding of participants and personnel to be at high risk for all studies.Growth. Supplementary feeding had positive effects on growth in low- and middle-income countries. Meta-analysis of the RCTs showed that supplemented children gained an average of 0.12 kg more than controls over six months (95% confidence interval (CI) 0.05 to 0.18, 9 trials, 1057 participants, moderate quality evidence). In the CBAs, the effect was similar; 0.24 kg over a year (95% CI 0.09 to 0.39, 1784 participants, very low quality evidence). In high-income countries, one RCT found no difference in weight, but in a CBA with 116 Aboriginal children in Australia, the effect on weight was 0.95 kg (95% CI 0.58 to 1.33). For height, meta-analysis of nine RCTs revealed that supplemented children grew an average of 0.27 cm more over six months than those who were not supplemented (95% CI 0.07 to 0.48, 1463 participants, moderate quality evidence). Meta-analysis of seven CBAs showed no evidence of an effect (mean difference (MD) 0.52 cm, 95% CI -0.07 to 1.10, 7 trials, 1782 participants, very low quality evidence). Meta-analyses of the RCTs demonstrated benefits for weight-for-age z-scores (WAZ) (MD 0.15, 95% CI 0.05 to 0.24, 8 trials, 1565 participants, moderate quality evidence), and height-for-age z-scores (HAZ) (MD 0.15, 95% CI 0.06 to 0.24, 9 trials, 4638 participants, moderate quality evidence), but not for weight-for-height z-scores MD 0.10 (95% CI -0.02 to 0.22, 7 trials, 4176 participants, moderate quality evidence). Meta-analyses of the CBAs showed no effects on WAZ, HAZ, or WHZ (very low quality evidence). We found moderate positive effects for haemoglobin (SMD 0.49, 95% CI 0.07 to 0.91, 5 trials, 300 participants) in a meta-analysis of the RCTs.Psychosocial outcomes. Eight RCTs in low- and middle-income countries assessed psychosocial outcomes. Our meta-analysis of two studies showed moderate positive effects of feeding on psychomotor development (SMD 0.41, 95% CI 0.10 to 0.72, 178 participants). The evidence of effects on cognitive development was sparse and mixed.We found evidence of substantial leakage. When feeding was given at home, children benefited from only 36% of the energy in the supplement. However, when the supplementary food was given in day cares or feeding centres, there was less leakage; children took in 85% of the energy provided in the supplement. Supplementary food was generally more effective for younger children (less than two years of age) and for those who were poorer/ less well-nourished. Results for sex were equivocal. Our results also suggested that feeding programmes which were given in day-care/feeding centres and those which provided a moderate-to-high proportion of the recommended daily intake (% RDI) for energy were more effective.

AUTHORS' CONCLUSIONS

Feeding programmes for young children in low- and middle-income countries can work, but good implementation is key.

Appraising the evidence for public health policy components using the quality and impact of component evidence assessment

An essential strategy expected to reduce the global burden of chronic and cardiovascular disease is evidence-based policy. However, it is often unknown what specific components should constitute an evidence-based policy intervention. We have developed an expedient method to appraise and compare the strengths of the evidence bases suggesting that individual components of a policy intervention will contribute to the positive public health impact of that intervention. Using a new definition of "best available evidence," the Quality and Impact of Component (QuIC) Evidence Assessment analyzes dimensions of evidence quality and evidence of public health impact to categorize multiple policy component evidence bases along a continuum of "emerging," "promising impact," "promising quality," and "best." QuIC was recently applied to components from 2 policy interventions to prevent and improve the outcomes of cardiovascular disease: public-access defibrillation and community health workers. Results illustrate QuIC's utility in international policy practice and research.

Risk perception in fire evacuation behavior revisited: definitions, related concepts, and empirical evidence

Risk perception (RP) is studied in many research disciplines (e.g., safety engineering, psychology, and sociology). Definitions of RP can be broadly divided into expectancy-value and risk-as-feeling approaches. In the present review, RP is seen as the personalization of the risk related to a current event, such as an ongoing fire emergency; it is influenced by emotions and prone to cognitive biases. We differentiate RP from other related concepts (e.g., situation awareness) and introduce theoretical frameworks relevant to RP in fire evacuation (e.g., Protective Action Decision Model and Heuristic-Systematic approaches). Furthermore, we review studies on RP during evacuation with a focus on the World Trade Center evacuation on September 11, 2001 and present factors modulating RP as well as the relation between perceived risk and protective actions. We summarize the factors that influence perception risk and discuss the direction of these relationships (i.e., positive or negative influence, or inconsequential) and conclude with presenting limitations of this review and an outlook on future research.

How do systematic reviews incorporate risk of bias assessments into the synthesis of evidence? A methodological study

Background

Systematic reviews (SRs) are expected to critically appraise included studies and privilege those at lowest risk of bias (RoB) in the synthesis. This study examines if and how critical appraisals inform the synthesis and interpretation of evidence in SRs.

Methods

All SRs published in March–May 2012 in 14 high-ranked medical journals and a sample from the Cochrane library were systematically assessed by two reviewers to determine if and how: critical appraisal was conducted; RoB was summarised at study, domain and review levels; and RoB appraisals informed the synthesis process.

Results

Of the 59 SRs studied, all except six (90%) conducted a critical appraisal of the included studies, with most using or adapting existing tools. Almost half of the SRs reported critical appraisal in a manner that did not allow readers to determine which studies included in a review were most robust. RoB assessments were not incorporated into synthesis in one-third (20) of the SRs, with their consideration more likely when reviews focused on randomised controlled trials. Common methods for incorporating critical appraisals into the synthesis process were sensitivity analysis, narrative discussion and exclusion of studies at high RoB. Nearly half of the reviews which investigated multiple outcomes and carried out study-level RoB summaries did not consider the potential for RoB to vary across outcomes.

Conclusions

The conclusions of the SRs, published in major journals, are frequently uninformed by the critical appraisal process, even when conducted. This may be particularly problematic for SRs of public health topics that often draw on diverse study designs.

Using the exhibited generalization approach to evaluate a carbon monoxide alarm ordinance

Current interests in enhancing the focus of external validity or transferability call for developing practical evaluation approaches and illustrating their applications in this area for meeting the need. This study takes the challenge by introducing an innovative evaluation approach, named the exhibited generalization approach, and applying it in evaluating the carbon monoxide (CO) alarm ordinance passed by Mecklenburg County, North Carolina. The stakeholders specifically asked evaluators to determine the answers to the following two questions: (1) Does the alarm ordinance work? (2) What generalizable information can the Mecklenburg experience provide to other jurisdictions trying to decide if the alarm ordinance's planning, implementation, adoption, and outcomes are transferable to their communities? This study illustrates how to apply the exhibited generalization approach to provide the stakeholders with answers to these questions. Our results indicate that the alarm ordinance was effective in increasing CO alarm ownerships and reducing CO poisoning cases. The evaluation provides potential users and other interested parties with the necessary information on contextual factors and the causal mechanism underlying the CO alarm ordinance, so that these parties and users could decide whether the Mecklenburg alarm ordinance would be transferable to their own communities. Discussions include implications of this study for contributing in further advancing evaluation theory in addressing transferability or external validity issues.

Evaluating causal relationships between urban built environment characteristics and obesity: a methodological review of observational studies

Background

Existing reviews identify numerous studies of the relationship between urban built environment characteristics and obesity. These reviews do not generally distinguish between cross-sectional observational studies using single equation analytical techniques and other studies that may support more robust causal inferences. More advanced analytical techniques, including the use of instrumental variables and regression discontinuity designs, can help mitigate biases that arise from differences in observable and unobservable characteristics between intervention and control groups, and may represent a realistic alternative to scarcely-used randomised experiments. This review sought first to identify, and second to compare the results of analyses from, studies using more advanced analytical techniques or study designs.

Methods

In March 2013, studies of the relationship between urban built environment characteristics and obesity were identified that incorporated (i) more advanced analytical techniques specified in recent UK Medical Research Council guidance on evaluating natural experiments, or (ii) other relevant methodological approaches including randomised experiments, structural equation modelling or fixed effects panel data analysis.

Results

Two randomised experimental studies and twelve observational studies were identified. Within-study comparisons of results, where authors had undertaken at least two analyses using different techniques, indicated that effect sizes were often critically affected by the method employed, and did not support the commonly held view that cross-sectional, single equation analyses systematically overestimate the strength of association.

Conclusions

Overall, the use of more advanced methods of analysis does not appear necessarily to undermine the observed strength of association between urban built environment characteristics and obesity when compared to more commonly-used cross-sectional, single equation analyses. Given observed differences in the results of studies using different techniques, further consideration should be given to how evidence gathered from studies using different analytical approaches is appraised, compared and aggregated in evidence synthesis.