1
|
Tinner L, Alonso Curbelo A. Intersectional discrimination and mental health inequalities: a qualitative study of young women's experiences in Scotland. Int J Equity Health 2024; 23:45. [PMID: 38424534 PMCID: PMC10903064 DOI: 10.1186/s12939-024-02133-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/19/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND In 2021, Scotland became the first UK country to launch a Women's Health Plan. This policy signals increasing commitment to broader ambitions surrounding gender equality in health. Research shows a connection between discrimination and health, representing a contributor to health inequalities. There remains sparse evidence on how certain groups experience discrimination that could be useful for policymaking. This research set out to address this evidence gap through exploring how discrimination shapes young women's experiences of mental health and inequalities in Scotland. METHODS We interviewed women aged 16-25 years (n=28), living in Scotland, UK, adopting an intersectional approach to recruitment and data analysis. We used a semi-structured topic guide to facilitate open discussion about discrimination and health. Transcripts were analysed by two researchers using Thematic Analysis and NVivo software. FINDINGS We identified three themes that illuminate intersectional discrimination and the impact on mental health. The first outlines how experiences of discrimination in school, work and public spaces (and the anticipation of such) creates stress leading to mental health problems, particularly for participants from ethnic minority groups. The second highlights the lack of support for mental health, both at structural and interpersonal levels, which was viewed by young women as a form of intersectional discrimination, largely because of their gender and age. Finally, we developed a mid-level theory termed the 'chain of dismissal' that displays that for both physical or mental health symptoms, young women's concerns are immediately "written off" as anxiety-related and in turn a natural attribute of young women. These themes show that discrimination has the potential to amplify mental health problems for young women and is a likely contributor to health inequalities. CONCLUSIONS Structural disadvantages such as racism intersect with gender and age to compound the experience of discrimination for marginalised young women. To improve mental health and reduce health inequalities for young women, multi-level approaches are needed, with strong consideration of how the structural and cultural landscape as well as assumptions made by healthcare professionals have critical implications for young women's health.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Ana Alonso Curbelo
- School of Social and Political Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
2
|
Tinner L, Kelly C, Caldwell D, Campbell R. Community mobilisation approaches to preventing adolescent multiple risk behaviour: a realist review. Syst Rev 2024; 13:75. [PMID: 38409098 PMCID: PMC10895861 DOI: 10.1186/s13643-024-02450-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/03/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts. METHODS This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory. FINDINGS We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired. CONCLUSIONS For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020205342.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK.
| | - Claire Kelly
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK
| | - Deborah Caldwell
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK
| |
Collapse
|
3
|
Porter A, Langford R, Summerbell C, Tinner L, Kipping R. A qualitative exploration of food portion size practices and awareness of food portion size guidance in first-time parents of one- to two-year-olds living in the UK. BMC Public Health 2023; 23:1779. [PMID: 37704981 PMCID: PMC10500748 DOI: 10.1186/s12889-023-16647-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 08/29/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND Food portion size guidance resources aimed at parents of young children in the UK are freely available from a number of credible sources. However, little is known about whether parents are aware of, and use, any of these resources to guide their food portioning practices. OBJECTIVES We aimed to explore the food portion size practices used by first-time parents living in the UK when feeding their one- to two-year-old child, and their awareness of and views on six food portion size guidance resources. METHODS Participants were recruited via parent Facebook groups and online parent forums. Online 1-1 semi-structured interviews were conducted, during which parents were shown images of six food portion size guidance resources to facilitate discussion. Data was analysed in NVivo 11 using a Reflexive Thematic Analysis approach. RESULTS Of the 27 participants, most were women (n = 25), white (n = 18), and educated to first degree level or higher (n = 24). First-time parents mostly relied on their own judgement and "instinct" to portion foods, based on their learned experience of how much their child ate on a day-to-day basis. This experience was used alongside physical indicators of food portion size, such as the size of children's dishware and food packaging. Most participants were unaware of any of the six food portion size guidance resources we showed them; only four had read any of the resources. Parents suggested they had previously sought advice about weaning from a range of sources (e.g. online, friends, community groups) but would be unlikely to seek out specific food portion size guidance. Parents suggested recommendations on food portion size should acknowledge and highlight parents' perception that "every child is different". CONCLUSIONS Existing food portion size guidance resources for parents of young children in the UK are ineffective as they have poor reach and impact. We suggest parents should be involved in developing novel strategies to promote age-appropriate consumption and healthy weight gain in young children.
Collapse
Affiliation(s)
- Alice Porter
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
- School for Public Health Research, NIHR, London, UK.
| | - Rebecca Langford
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carolyn Summerbell
- School for Public Health Research, NIHR, London, UK
- Department of Sport and Exercise Sciences, Durham University, Durham, UK
| | - Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ruth Kipping
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- School for Public Health Research, NIHR, London, UK
| |
Collapse
|
4
|
Tinner L, Holman D, Ejegi-Memeh S, Laverty AA. Use of Intersectionality Theory in Interventional Health Research in High-Income Countries: A Scoping Review. Int J Environ Res Public Health 2023; 20:6370. [PMID: 37510601 PMCID: PMC10379482 DOI: 10.3390/ijerph20146370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/12/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Intersectionality theory posits that considering a single axis of inequality is limited and that considering (dis)advantage on multiple axes simultaneously is needed. The extent to which intersectionality has been used within interventional health research has not been systematically examined. This scoping review aimed to map out the use of intersectionality. It explores the use of intersectionality when designing and implementing public health interventions, or when analysing the impact of these interventions. METHODS We undertook systematic searches of Medline and Scopus from inception through June 2021, with key search terms including "intersectionality", "interventions" and "public health". References were screened and those using intersectionality and primary data from high-income countries were included and relevant data synthesised. RESULTS After screening 2108 studies, we included 12 studies. Six studies were qualitative and focused on alcohol and substance abuse (two studies), mental health (two studies), general health promotion (one study) and housing interventions (one study). The three quantitative studies examined mental health (two studies) and smoking cessation (one study), while the three mixed-method studies examined mental health (two studies) and sexual exploitation (one study). Intersectionality was used primarily to analyse intervention effects (eight studies), but also for intervention design (three studies), and one study used it for both design and analysis. Ethnicity and gender were the most commonly included axes of inequality (11 studies), followed by socio-economic position (10 studies). Four studies included consideration of LGBTQ+ and only one considered physical disability. Intersectional frameworks were used by studies to formulate specific questions and assess differences in outcomes by intersectional markers of identity. Analytical studies also recommended intersectionality approaches to improve future treatments and to structure interventions to focus on power and structural dynamics. CONCLUSIONS Intersectionality theory is not yet commonly used in interventional health research, in either design or analysis. Conditions such as mental health have more studies using intersectionality, while studies considering LGBTQ+ and physical disability as axes of inequality are particularly sparse. The lack of studies in our review suggests that theoretical and methodological advancements need to be made in order to increase engagement with intersectionality in interventional health.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1UD, UK
| | - Daniel Holman
- Department of Sociological Studies, The University of Sheffield, The Wave, 2 Whitham Road, Sheffield S10 2AH, UK
| | - Stephanie Ejegi-Memeh
- Department of Sociological Studies, The University of Sheffield, The Wave, 2 Whitham Road, Sheffield S10 2AH, UK
| | - Anthony A Laverty
- Public Health Policy Evaluation, School of Public Health, Imperial College London, London SW7 2BX, UK
| |
Collapse
|
5
|
Rojas-García A, Holman D, Tinner L, Ejegi-Memeh S, Ben-Shlomo Y, Laverty AA. Use of intersectionality theories in interventional health research in high-income countries: a systematic scoping review. Lancet 2022; 400 Suppl 1:S58. [PMID: 36930004 DOI: 10.1016/s0140-6736(22)02268-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intersectionality theory suggests that multiple forms of inequality need to be considered simultaneously. The extent to which intersectionality has been used within interventional health research has not been systematically examined. This scoping review explores the use of intersectionality when designing and implementing interventions to reduce health inequalities, or when analysing the impact of these interventions. METHODS We did a systematic search of MEDLINE and Scopus for articles published from inception up to June 30, 2021, with the key search terms "intersectionality", "interventions", and "public health". References were screened and those including use of intersectionality and primary data from high-income countries were included and relevant data synthesised. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines extension for scoping reviews. FINDINGS 2108 studies were screened, of which 12 met inclusion criteria Six (50%) of the 12 studies were qualitative and focused on alcohol and substance abuse (two studies), mental health (two studies), general health promotion (one study), and housing interventions (one study). The three quantitative studies (25%) examined mental health (two studies) and smoking cessation (one study), whereas the three mixed-methods studies (25%) examined mental health (two studies) and sexual exploitation (one study). Nine studies (75%) used intersectionality to analyse intervention effects, two studies (25%) used intersectionality for intervention design, and one study (8%) used intersectionality for both design and analysis of an intervention. Ethnicity and gender were the most commonly included axes of inequality (11 studies [92%]), followed by socioeconomic status (ten studies [83%]). Only four studies (33%) included consideration of LGBTQ+ individuals and only one (8%) considered physical disabilities. INTERPRETATION Intersectionality theories are not yet commonly used in either the design or the evaluation of interventional health research, and evidence on the implementation of some key elements of intersectionality is still scarce. Studies on some conditions, such as mental health, have more often used intersectionality, whereas studies considering the LGBTQ+ community and individuals with physical disabilities as axes of inequality are particularly scarce. FUNDING National Institute for Health and Care Research School for Public Health Research.
Collapse
Affiliation(s)
- Antonio Rojas-García
- Public Health Policy Evaluation, School of Public Health, Imperial College London, London, UK; Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - Laura Tinner
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Stephanie Ejegi-Memeh
- Division of Nursing and Midwifery, Health Sciences School, University of Sheffield, Sheffield, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Anthony A Laverty
- Public Health Policy Evaluation, School of Public Health, Imperial College London, London, UK.
| |
Collapse
|
6
|
Tinner L. Exploring young people's perceptions of health and inequality through art: a co-produced qualitative study. Lancet 2022; 400 Suppl 1:S6. [PMID: 36930006 DOI: 10.1016/s0140-6736(22)02216-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite increased focus on adolescence, young people's voices are often undervalued and underrepresented in inequalities research. Through exploring young people's perceptions of health and inequality, we might understand how public health interventions can be more effective and equitable. Engaging with youth through art enables self-expression on these complex and sensitive topics. This qualitative project aimed to explore young people's perceptions of their health, inequality, and their aspirations within the Bristol context to inform local policy and everyday practice for adolescent health. METHODS Creative focus groups, co-produced with a young artist, were done at three community centres in deprived areas of Bristol, outlined by the Index of Multiple Deprivation. Participants engaged in art and were guided through discussion by a semi-structured topic guide. A thematic approach to analysis was adopted. Written informed consent was obtained for participants aged 16 years and older and parental consent or participant assent obtained from participants younger than 16 years. The study was reviewed by the University of Bristol Health Sciences Faculty Research Ethics Committees. FINDINGS 30 children aged 11-18 years took part. Five themes represented how participants understood health and inequality in Bristol. Adolescents felt forgotten, which they exemplified through a scarcity of age-appropriate activities and public spaces. Participants saw mental health and health risk behaviours such as alcohol and unhealthy diet as major problems for their generation, and highlighted inequalities across these factors. They described how inequalities are experienced in their everyday lives, such as through differential Wi-Fi access, gentrification visible in architecture, experiences of crime, and feeling safe. All felt uncertain about their future and thought they could be better supported around education and employment decisions. Participants thought all issues were exacerbated by the Covid-19 pandemic. INTERPRETATION There is strong awareness of negative health factors and socioeconomic inequalities across youth in Bristol. Young people's perceptions and experiences signal the need for city-wide structural and age-specific policies for adolescents, particularly in deprived areas, to support them in living a healthy life. FUNDING The University of Bristol, Wellcome Trust.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol UK; ESRC Policy Fellow in Health and Social Care Analysis, Scottish Government, Edinburgh, UK.
| |
Collapse
|
7
|
Tinner L, Palmer JC, Lloyd EC, Caldwell DM, MacArthur GJ, Dias K, Langford R, Redmore J, Wittkop L, Watkins SH, Hickman M, Campbell R. Individual-, family- and school-based interventions to prevent multiple risk behaviours relating to alcohol, tobacco and drug use in young people aged 8-25 years: a systematic review and meta-analysis. BMC Public Health 2022; 22:1111. [PMID: 35658920 PMCID: PMC9165543 DOI: 10.1186/s12889-022-13072-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Engagement in multiple substance use risk behaviours such as tobacco smoking, alcohol and drug use during adolescence can result in adverse health and social outcomes. The impact of interventions that address multiple substance use risk behaviours, and the differential impact of universal versus targeted approaches, is unclear given findings from systematic reviews have been mixed. Our objective was to assess effects of interventions targeting multiple substance use behaviours in adolescents. METHODS Eight databases were searched to October 2019. Individual and cluster randomised controlled trials were included if they addressed two or more substance use behaviours in individuals aged 8-25 years. Data were pooled in random-effects meta-analyses, reported by intervention and setting. Quality of evidence was assessed using GRADE. Heterogeneity was assessed using between-study variance, τ2 and Ι2, and the p-value of between-study heterogeneity statistic Q. Sensitivity analyses were undertaken using the highest and lowest intra-cluster correlation coefficient (ICC). RESULTS Of 66 included studies, most were universal (n=52) and school-based (n=41). We found moderate quality evidence that universal school-based interventions are likely to have little or no short-term benefit (up to 12 months) in relation to alcohol use (OR 0.94, 95% CI: 0.84, 1.04), tobacco use (OR 0.98, 95% CI: 0.83, 1.15), cannabis use (OR 1.06, 95% CI: 0.86, 1.31) and other illicit drug use (OR 1.09, 95% CI: 0.85, 1.39). For targeted school-level interventions, there was low quality evidence of no or a small short-term benefit: alcohol use (OR 0.90, 95% CI: 0.74-1.09), tobacco use (OR 0.86, 95% CI: 0.66, 1.11), cannabis use (OR 0.84, 95% CI: 0.66-1.07) and other illicit drug use (OR 0.79, 95% CI 0.62-1.02). There were too few family-level (n=4), individual-level (n=2) and combination level (n=5) studies to draw confident conclusions. Sensitivity analyses of ICC did not change results. CONCLUSIONS There is low to moderate quality evidence that universal and targeted school-level interventions have no or a small beneficial effect for preventing substance use multiple risk behaviours in adolescents. Higher quality trials and study reporting would allow better evidence syntheses, which is needed given small benefit of universal interventions can have high public health benefit. TRIAL REGISTRATION Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD011374. DOI: 10.1002/14651858.CD011374.
Collapse
Affiliation(s)
- Laura Tinner
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Jennifer C Palmer
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
- MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
| | - E Caitlin Lloyd
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
- New York State Psychiatric Institute, New York, New York, USA
| | - Deborah M Caldwell
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Georgie J MacArthur
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Kaiseree Dias
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Rebecca Langford
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - James Redmore
- York Teaching Hospitals NHS Foundation Trust, Wiggington Road, York, UK
| | - Linda Wittkop
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | | | - Matthew Hickman
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Rona Campbell
- Bristol Medical School, Population Health Sciences, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| |
Collapse
|
8
|
Tinner L, Wright C, Heron J, Caldwell D, Campbell R, Hickman M. Correction to: Is adolescent multiple risk behaviour associated with reduced socioeconomic status in young adulthood and do those with low socioeconomic backgrounds experience greater negative impact? Findings from two UK birth cohort studies. BMC Public Health 2021; 21:1777. [PMID: 34592964 PMCID: PMC8482566 DOI: 10.1186/s12889-021-11764-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN, UK.
| | - Caroline Wright
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN, UK
| | - Jon Heron
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN, UK
| | - Deborah Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN, UK
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN, UK
| |
Collapse
|
9
|
Tinner L, Wright C, Heron J, Caldwell D, Campbell R, Hickman M. Is adolescent multiple risk behaviour associated with reduced socioeconomic status in young adulthood and do those with low socioeconomic backgrounds experience greater negative impact? Findings from two UK birth cohort studies. BMC Public Health 2021; 21:1614. [PMID: 34479524 PMCID: PMC8414729 DOI: 10.1186/s12889-021-11638-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Adolescent multiple risk behaviour (MRB) is associated with negative outcomes such as police arrests, unemployment and premature mortality and morbidity. What is unknown is whether MRB is associated with socioeconomic status (SES) in adulthood. We test whether adolescent MRB is associated with socioeconomic status (SES) in young adulthood and whether it is moderated by early life SES variables. METHODS Prospective cohort studies; British Cohort Study 1970 (BCS70) and Avon Longitudinal Study of Parents and Children (ALSPAC), born in 1991-1992, were used and two comparable MRB variables were derived. Logistic regression was used to determine the association between MRB and young adult SES. The moderating effect of three early life SES variables was assessed using logistic regression models with and without interaction parameters. Evidence to support the presence of moderation was determined by likelihood ratio tests ≤p = 0.05. Multiple imputation was used to account for missing data. RESULTS Adolescents had a median of two risk behaviours in BCS70 and three in ALSPAC. Adolescent MRB was negatively associated with young adult SES (university degree attainment) in BCS70 (OR 0.81, 95% CI: 0.76, 0.86) and ALSPAC (OR 0.85, 95% CI: 0.82, 0.88). There was a dose response relationship, with each additional risk behaviour resulting in reduced odds of university degree attainment. MRB was associated occupational status at age 34 in BCS70 (OR 0.86 95% CI: 0.82, 0.90). In BCS70, there was evidence that maternal education (p = 0.03), parental occupational status (p = 0.009) and household income (p = 0.03) moderated the effect of adolescent MRB on young adult SES in that the negative effect of MRB is stronger for those with low socioeconomic backgrounds. No evidence of moderation was found in the ALSPAC cohort. CONCLUSIONS Adolescence appears to be a critical time in the life course to address risk behaviours, due to the likelihood that behaviours established here may have effects in adulthood. Intervening on adolescent MRB could improve later SES outcomes and thus affect health outcomes later in life. Evidence for a moderation effect in the BCS70 but not ALSPAC suggests that more detailed measures should be investigated to capture the nuance of contemporary young adult SES.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN UK
| | - Caroline Wright
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN UK
| | - Jon Heron
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN UK
| | - Deborah Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN UK
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, BG3 Oakfield House, Bristol, BS8 2BN UK
| |
Collapse
|
10
|
Tinner L, Caldwell D, Campbell R. Correction to: Community mobilisation approaches to preventing and reducing adolescent multiple risk behaviour: a realist review protocol. Syst Rev 2021; 10:168. [PMID: 34099043 PMCID: PMC8186135 DOI: 10.1186/s13643-021-01720-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2023] Open
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK.
| | - Deborah Caldwell
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, BS8 2PL, UK
| |
Collapse
|
11
|
Tinner L, Caldwell D, Hickman M, Campbell R. Understanding adolescent health risk behaviour and socioeconomic position: A grounded theory study of UK young adults. Sociol Health Illn 2021; 43:528-544. [PMID: 33635557 PMCID: PMC8168338 DOI: 10.1111/1467-9566.13240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 12/04/2020] [Accepted: 12/14/2020] [Indexed: 06/12/2023]
Abstract
Health risk behaviours such as tobacco smoking, excessive alcohol consumption, drug use, unhealthy diet and unprotected sexual intercourse contribute to the global burden of non-communicable diseases and are often initiated in adolescence. An individualistic focus on 'health risk behaviours' has resulted in behaviour change strategies that are potentially ineffective and increase inequalities. We conducted a grounded theory study of 25 young adults to increase the limited qualitative evidence base surrounding young people, health risk behaviours and socioeconomic inequalities. We found that health risk behaviours were perceived as class markers, manifesting as class stigma, leading some participants from lower socioeconomic backgrounds to employ strategies to avoid such behaviours. Peers and family were core constructs for understanding the relationship between health risk behaviours and socioeconomic life trajectories. However, individualism and choice were consistently expressed as the overriding narrative for understanding health risk behaviour and socioeconomic position during the transition to adulthood. The use of 'personal responsibility' discourse by young adults, we argue, highlights the need for a public health focus on achieving structural changes as opposed to individualised approaches to avoid reinforcing neoliberal ideologies that serve to marginalise and maintain social inequalities.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Deborah Caldwell
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Matthew Hickman
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Rona Campbell
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| |
Collapse
|
12
|
Tinner L, Wright C, Heron J, Caldwell D, Campbell R, Hickman M. Multiple risk behaviour and socioeconomic status during the transition from adolescence to adulthood. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Multiple risk behaviour (MRB) means the occurrence of two or more risk behaviours and is associated with a range of negative outcomes. What is unknown is whether MRB is associated with socioeconomic status (SES) in adulthood. This study aimed to examine the association between adolescent MRB and young adult SES and whether those who experienced early life socioeconomic disadvantage also faced greater negative impact of adolescent MRB.
Methods
Two prospective birth cohort studies; British Cohort Study 1970 (BCS70) and Avon Longitudinal Study of Parents and Children (ALSPAC), born in 1991-1992, were used. Logistic regression assessed the association between MRB and young adult SES. Three early life SES variables were examined for their moderating effect on the association using models with and without interaction parameters. Likelihood ratio tests ≤p=0.05 indicated evidence to support moderation. Multiple imputation was used to account for missing data.
Results
Adolescent MRB was negatively associated with young adult SES (university degree attainment) in BCS70 (OR 0.81, 95% CI: 0.76, 0.86) and ALSPAC (OR 0.85, 95% CI: 0.82, 0.88). There was a dose response, with each additional risk behaviour resulting in reduced odds of university degree attainment. In BCS70, maternal education (p = 0.03), parental occupation (p = 0.009) and household income (p = 0.03) moderated the effect of adolescent MRB on young adult SES. The effect of MRB on university degree attainment was stronger for those from poorer socioeconomic backgrounds. No evidence of moderation was found in ALSPAC.
Conclusions
Adolescence is a critical time to address MRB as behaviours established here may have effects in adulthood. Intervening on adolescent MRB may improve later SES and thus health outcomes later in life. Evidence for a moderation effect in the BCS70 but not ALSPAC suggests that measures should be investigated for their ability to capture the nuance of contemporary young adult SES.
Key messages
Intervening on adolescent multiple risk behaviour could improve socioeconomic life chances in young adulthood. Variables that capture the nuance of contemporary young adult socioeconomic status should be explored.
Collapse
Affiliation(s)
- L Tinner
- Population Health Sciences, University of Bristol, Bristol, UK
| | - C Wright
- Population Health Sciences, University of Bristol, Bristol, UK
| | - J Heron
- Population Health Sciences, University of Bristol, Bristol, UK
| | - D Caldwell
- Population Health Sciences, University of Bristol, Bristol, UK
| | - R Campbell
- Population Health Sciences, University of Bristol, Bristol, UK
| | - M Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| |
Collapse
|
13
|
Kipping R, Langford R, Brockman R, Wells S, Metcalfe C, Papadaki A, White J, Hollingworth W, Moore L, Ward D, Campbell R, Kadir B, Tinner L, Er V, Dias K, Busse H, Collingwood J, Nicholson A, Johnson L, Jago R. Child-care self-assessment to improve physical activity, oral health and nutrition for 2- to 4-year-olds: a feasibility cluster RCT. Public Health Res 2019. [DOI: 10.3310/phr07130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background
The Nutrition And Physical Activity Self Assessment for Child Care (NAP SACC) intervention has shown evidence of effectiveness in the USA but not been adapted or assessed for effectiveness in the UK.
Objectives
To evaluate the feasibility and acceptability of implementing NAP SACC in the UK.
Design
Adaptation and development of NAP SACC and feasibility cluster randomised controlled trial (RCT) including process and economic evaluations. Substudies assessed mediator questionnaire test–retest reliability and feasibility of food photography methods.
Setting
Nurseries, staff and parents in North Somerset, Cardiff, Gloucestershire and Bristol.
Participants
Development – 15 early years/public health staff and health visitors, 12 nursery managers and 31 parents. RCT – 12 nurseries and 31 staff, four partners and 168 children/parents. Mediator substudy – 82 parents and 69 nursery staff. Food photography substudy – four nurseries, 18 staff and 51 children.
Intervention
NAP SACC UK partners supported nurseries to review policies and practices and set goals to improve nutrition, oral health and physical activity (PA) over 5 months. Two workshops were delivered to nursery staff by local experts. A home component [website, short message service (SMS) and e-mails] supported parents. The control arm continued with usual practice.
Main outcome measures
Feasibility and acceptability of the intervention and methods according to prespecified criteria.
Data sources
Qualitative data to adapt the intervention. Measurements with children, parents and staff at baseline and post intervention (8–10 months after baseline). Interviews with nursery managers, staff, parents and NAP SACC UK partners; observations of training, workshops and meetings. Nursery environment observation, nursery Review and Reflect score, and resource log. Child height and weight, accelerometer-determined PA and sedentary time, screen time and dietary outcomes using the Child and Diet Evaluation Tool. Staff and parent questionnaires of knowledge, motivation and self-efficacy. Child quality of life and nursery, family and health-care costs. Food photography of everything consumed by individual children and staff questionnaire to assess acceptability.
Results
Thirty-two per cent (12/38) of nurseries and 35.3% (168/476) of children were recruited; no nurseries withdrew. The intervention was delivered in five out of six nurseries, with high levels of fidelity and acceptability. Partners found it feasible but had concerns about workload. The child loss to follow-up rate was 14.2%. There was suggestion of promise in intervention compared with control nurseries post intervention for snacks, screen time, proportion overweight or obese and accelerometer-measured total PA and moderate to vigorous PA. Many parental and nursery knowledge and motivation mediators improved. The average cost of delivering the intervention was £1184 per nursery excluding partner training, and the average cost per child was £27. Fourteen per cent of parents used the home component and the mediator questionnaire had good internal consistency and test–retest reliability. Photography of food was acceptable and feasible.
Limitations
Following nursery leavers was difficult. Accelerometer data, diet data and environmental assessment would have been more reliable with 2 days of data.
Conclusions
The NAP SACC UK intervention and methods were found to be feasible and acceptable to participants, except for the home component. There was sufficient suggestion of promise to justify a definitive trial.
Future work
A multicentre cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of NAP SACC UK has been funded by NIHR and will start in July 2019 (PHR NIHR 127551).
Trial registration
Current Controlled Trials ISRCTN16287377.
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. 7, No. 13. See the NIHR Journals Library website
for further project information. Funding was also provided by the North
Somerset and Gloucestershire Councils, Development and Evaluation of Complex
Interventions for Public Health Improvement (DECIPHer) (MR/KO232331/1), and
the Elizabeth Blackwell Institute.
Collapse
Affiliation(s)
- Ruth Kipping
- Bristol Medical School, University of Bristol, Bristol, UK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rebecca Langford
- Bristol Medical School, University of Bristol, Bristol, UK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rowan Brockman
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Wells
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Angeliki Papadaki
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| | - James White
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Laurence Moore
- Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Dianne Ward
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rona Campbell
- Bristol Medical School, University of Bristol, Bristol, UK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bryar Kadir
- Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Laura Tinner
- Bristol Medical School, University of Bristol, Bristol, UK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Vanessa Er
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Kaiseree Dias
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Heide Busse
- Bristol Medical School, University of Bristol, Bristol, UK
- Centre for the Development and Evaluation of Complex Interventions for Public Health Improvement (DECIPHer), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Laura Johnson
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| | - Russell Jago
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| |
Collapse
|
14
|
Tinner L, Kipping R, White J, Jago R, Metcalfe C, Hollingworth W. Cross-sectional analysis of physical activity in 2-4-year-olds in England with paediatric quality of life and family expenditure on physical activity. BMC Public Health 2019; 19:846. [PMID: 31253117 PMCID: PMC6599301 DOI: 10.1186/s12889-019-7129-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 06/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many children do not meet the recommended level of daily physical activity, even with the widely acknowledged health benefits associated with being physically active. There is a need to establish factors related to physical activity in children so that public health interventions may be appropriately designed. We investigated the association between Pediatric Quality of Life Inventory (PedsQL), family expenditure on physical activity and objectively measured daily physical activity in 2-4-year-old children. METHODS Cross-sectional study with a sample of 81 UK preschool children taking part in the NAPSACC UK feasibility randomized controlled trial. Descriptive statistics are presented. We undertook Student t-tests to establish differences in physical activity by gender, age, parental education and nursery versus non-nursery days. Mixed effects linear regressions were used to model the association between minutes spent physically activity, minutes spent in moderate-to-vigorous (MVPA) physical activity and PedsQL scores (physical and psychosocial) and family expenditure on physical activity. RESULTS Most children (88.9%) did not engage in the recommended 180 min daily physical activity. There was mean (SD) of 141.9 (33.1) daily minutes of physically activity and 22.2 min per day (SD = 9.9) of MVPA. Boys and older children were more physically active. Children were more active on nursery days. There was no difference in physical activity by parental education. Half of the sample parents (50.6%) spent less than £9.00 weekly on their pre-schooler's physical activity. Children within the highest tertile of PedsQL physical functioning scores had higher levels of MVPA (3.6, 95% CI: - 1.3-8.4, p-value 0.15), although confidence intervals crossed the null in the adjusted model. We found no evidence of an association between positive PedsQL psychosocial scores, or higher parental expenditure on physical activity, with the physical activity variables. CONCLUSIONS Children in this sample were not meeting the recommended 180 min of daily physical activity. The 2-4-year-olds were most active on nursery days. There is no evidence of an association between better PedsQL physical scores and higher levels of MVPA. There was no evidence of an association between expenditure on physical activity and time spent physically active. Further examination in larger representative datasets is needed.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN, UK.
| | - Ruth Kipping
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN, UK
| | - James White
- Centre for Trials Research, Cardiff University, Cardiff, CF14 4YS, UK
| | - Russell Jago
- Centre for Exercise, Nutrition & Health Sciences, School for Policy Studies, University of Bristol, Bristol, BS8 1TZ, UK.,The National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West) at University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Chris Metcalfe
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN, UK
| |
Collapse
|
15
|
Tinner L, Caldwell D, Hickman M, MacArthur GJ, Gottfredson D, Lana Perez A, Moberg DP, Wolfe D, Campbell R. Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence. BMC Public Health 2018; 18:1180. [PMID: 30326897 PMCID: PMC6192072 DOI: 10.1186/s12889-018-6042-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 09/17/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Multiple risk behaviour (MRB) refers to two or more risk behaviours such as smoking, drinking alcohol, poor diet and unsafe sex. Such behaviours are known to co-occur in adolescence. It is unknown whether MRB interventions are equally effective for young people of low and high socioeconomic status (SES). There is a need to examine these effects to determine whether MRB interventions have the potential to narrow or widen inequalities. METHODS Two Cochrane systematic reviews that examined interventions to reduce adolescent MRB were screened to identify universal interventions that reported SES. Study authors were contacted, and outcome data stratified by SES and intervention status were requested. Risk behaviour outcomes alcohol use, smoking, drug use, unsafe sex, overweight/obesity, sedentarism, peer violence and dating violence were examined in random effects meta-analyses and subgroup analyses conducted to explore differences between high SES and low SES adolescents. RESULTS Of 49 studies reporting universal interventions, only 16 also reported having measured SES. Of these 16 studies, four study authors provided data sufficient for subgroup analysis. There was no evidence of subgroup differences for any of the outcomes. For alcohol use, the direction of effect was the same for both the high SES group (RR 1.26, 95% CI: 0.96, 1.65, p = 0.09) and low SES group (RR 1.14, 95% CI: 0.98, 1.32, p = 0.08). The direction of effect was different for smoking behaviour in favour of the low SES group (RR 0.83, 95% CI: 0.66, 1.03, p = 0.09) versus the high SES group (RR 1.16, 95% CI: 0.82, 1.63, p = 0.39). For drug use, the direction of effect was the same for both the high SES group (RR 1.29, 95% CI: 0.97, 1.73, p = 0.08) and the low SES group (RR 1.28, 95% CI: 0.84, 1.96, p = 0.25). CONCLUSIONS The majority of studies identified did not report having measured SES. There was no evidence of subgroup difference for all outcomes analysed among the four included studies. There is a need for routine reporting of demographic information within studies so that stronger evidence of effect by SES can be demonstrated and that interventions can be evaluated for their impact on health inequalities.
Collapse
Affiliation(s)
- Laura Tinner
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN UK
| | - Deborah Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN UK
| | - Georgina J MacArthur
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN UK
| | - Denise Gottfredson
- Department of Criminology and Criminal Justice, University of Maryland, College Park, Prince George’s, MD USA
| | - Alberto Lana Perez
- Department of Preventive Medicine and Public Health, School of Medicine and Health Sciences, University of Oviedo, Oviedo, Spain
| | - D Paul Moberg
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - David Wolfe
- Faculty of Education, Western University, Ontario, Canada
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, Canygne Hall, Bristol, BS8 2BN UK
| |
Collapse
|