A comparative study of industry responses to government consultations about alcohol and gambling in the UK.

BACKGROUND: There is growing evidence that common strategies are used across unhealthy commodity industries (UCIs) to influence policy decisions in line with their commercial interests. To date, there have been relatively few studies comparing corporate political activity (CPA) across UCIs, especially comparing the alcohol and gambling industries. METHODS: A comparative and inductive thematic analysis of alcohol and gambling industry submissions to two House of Lords (HoL) inquiries in the UK was conducted. Themes in the framing, arguments and strategies used by the alcohol and gambling industries in CPA were compared. RESULTS: Alcohol and gambling industry responses largely used the same framings, both in terms of the problems and solutions. This included arguing that harms are only experienced by a 'minority' of people, emphasising individual responsibility and shifting blame for harms to other industry actors. They promoted targeted or localised solutions to these harms, in place of more effective population level solutions, and emphasised the perceived harms of introducing regulation not in the industries' interests. CONCLUSIONS: These findings are consistent with previous literature suggesting that UCIs use the same framing and arguments to shape the narrative around their harms and solutions to those harms. This study also identified novel strategies such as shifting blame of harms to other industry actors. Policy makers should be aware of these strategies to avoid undue industry influence on policy decisions and understanding commonalities in strategies may help to inform more effective public health responses across all UCIs.

Concepts of responsibility in the German media debate on sugar taxation: a qualitative framing analysis.

BACKGROUND: Framing plays an important role in health-policy processes. Responsibility for health is a salient and contested concept in the framing around food policies, such as sugar taxes. To deepen the understanding of the sugar tax process in Germany and contribute to a better understanding of how responsibility frames are used in debates on health policies, this study investigated responsibility concepts underlying the German media debate on sugar taxation. METHODS: We analyzed 114 national German newspaper articles, published between January 2018 and March 2019, following an inductive thematic analysis approach with an additional deductive focus on responsibility. We identified important contested concepts around sugar taxation, analyzed their combination into narrative frames, and scrutinized those narrative frames for underlying responsibility concepts. RESULTS: First, we identified important contested concepts regarding problems, actors and solutions (i.e. sugar tax and its potential alternatives). Those laid the basis for 13 narrative frames, of which the 'unscrupulous industry', 'government failure', 'vulnerable youth' and the 'oversimplification', 'responsible industry' and 'nanny state' frames were most salient. Within the narrative frames, we found a dominance of societal responsibility framing with a conflict between binding, legislative measures and voluntary solutions in cooperation with the food and beverages industry. CONCLUSIONS: Questions around societal responsibility for health and corporate social responsibility framing become more salient in sugar tax debates. Future research should, therefore, investigate how public health advocates can successfully engage with corporate social responsibility narratives, and how legislative measures can be framed in ways that engender trust in governmental actions.

Qualitative process evaluation from a complex systems perspective: A systematic review and framework for public health evaluators.

BACKGROUND: Public health evaluation methods have been criticized for being overly reductionist and failing to generate suitable evidence for public health decision-making. A "complex systems approach" has been advocated to account for real world complexity. Qualitative methods may be well suited to understanding change in complex social environments, but guidance on applying a complex systems approach to inform qualitative research remains limited and underdeveloped. This systematic review aims to analyze published examples of process evaluations that utilize qualitative methods that involve a complex systems perspective and proposes a framework for qualitative complex system process evaluations. METHODS AND FINDINGS: We conducted a systematic search to identify complex system process evaluations that involve qualitative methods by searching electronic databases from January 1, 2014-September 30, 2019 (Scopus, MEDLINE, Web of Science), citation searching, and expert consultations. Process evaluations were included if they self-identified as taking a systems- or complexity-oriented approach, integrated qualitative methods, reported empirical findings, and evaluated public health interventions. Two reviewers independently assessed each study to identify concepts associated with the systems thinking and complexity science traditions. Twenty-one unique studies were identified evaluating a wide range of public health interventions in, for example, urban planning, sexual health, violence prevention, substance use, and community transformation. Evaluations were conducted in settings such as schools, workplaces, and neighborhoods in 13 different countries (9 high-income and 4 middle-income). All reported some utilization of complex systems concepts in the analysis of qualitative data. In 14 evaluations, the consideration of complex systems influenced intervention design, evaluation planning, or fieldwork. The identified studies used systems concepts to depict and describe a system at one point in time. Only 4 evaluations explicitly utilized a range of complexity concepts to assess changes within the system resulting from, or co-occurring with, intervention implementation over time. Limitations to our approach are including only English-language papers, reliance on study authors reporting their utilization of complex systems concepts, and subjective judgment from the reviewers relating to which concepts featured in each study. CONCLUSION: This study found no consensus on what bringing a complex systems perspective to public health process evaluations with qualitative methods looks like in practice and that many studies of this nature describe static systems at a single time point. We suggest future studies use a 2-phase framework for qualitative process evaluations that seek to assess changes over time from a complex systems perspective. The first phase involves producing a description of the system and identifying hypotheses about how the system may change in response to the intervention. The second phase involves following the pathway of emergent findings in an adaptive evaluation approach.

Reducing the Strength: a mixed methods evaluation of alcohol retailers' willingness to voluntarily reduce the availability of low cost, high strength beers and ciders in two UK local authorities.

BACKGROUND: Reducing the Strength is an increasingly popular intervention in which local authorities ask retailers to stop selling 'super-strength' beers and ciders. The intervention cannot affect alcohol availability, nor consumption, unless retailers participate. In this paper, we ask whether and why retailers choose or refuse to self-impose restrictions on alcohol sales in this way. METHODS: Mixed method assessment of retailers' participation in Reducing the Strength in two London (UK) local authorities. Compliance rates and the cheapest available unit of alcohol at each store were assessed. Qualitative interviews with retailer managers and staff (n = 39) explored attitudes towards the intervention and perceptions of its impacts. RESULTS: Shops selling super-strength across both areas fell from 78 to 25 (18 % of all off-licences). The median price of the cheapest unit of alcohol available across all retailers increased from £0.29 to £0.33 and in shops that participated in Reducing the Strength it rose from £0.33 to £0.43. The project received a mixed response from retailers. Retailers said they participated to deter disruptive customers, reduce neighbourhood disruptions and to maintain a good relationship with the local authority. Reducing the Strength participants and non-participants expressed concern about its perceived financial impact due to customers shopping elsewhere for super-strength. Some felt that customers' ability to circumvent the intervention would limit its effectiveness and that a larger scale compulsory approach would be more effective. CONCLUSIONS: Reducing the Strength can achieve high rates of voluntary compliance, reduce availability of super-strength and raise the price of the cheapest available unit of alcohol in participating shops. Questions remain over the extent to which voluntary interventions of this type can achieve wider social or health goals if non-participating shops attract customers from those who participate.

Does better than expected life expectancy in areas of disadvantage indicate health resilience? Stakeholder perspectives and possible explanations.

Some places have better than expected health trends despite being disadvantaged in other ways. Thematic analysis of qualitative data from stakeholders (N = 25) in two case studies of disadvantaged local authorities the North West and South East of England assessed explanations for the localities' apparent health resilience. Participants identified ways of working that might contribute to improved life expectancy, such as partnering with third sector, targeting and outcome driven action. Stakeholders were reluctant to assume credit for better-than-expected health outcomes. External factors such as population change, national politics and finances were considered crucial. Local public health stakeholders regard their work as important but unlikely to cause place-centred health resilience.

Reducing alcohol harms whilst minimising impact on hospitality businesses: 'Sweetspot' policy options.

BACKGROUND: During COVID-19, hospitality businesses (e.g. bars, restaurants) were closed/restricted whilst off-sales of alcohol increased, with health consequences. Post-covid, governments face lobbying to support such businesses, but many health services remain under pressure. We appraised 'sweetspot' policy options: those with potential to benefit public services and health, whilst avoiding or minimising negative impact on the hospitality sector. METHODS: We conducted rapid non-systematic evidence reviews using index papers, citation searches and team knowledge to summarise the literature relating to four possible 'sweetspot' policy areas: pricing interventions (9 systematic reviews (SR); 14 papers/reports); regulation of online sales (1 SR; 1 paper); place-shaping (2 SRs; 18 papers/reports); and violence reduction initiatives (9 SRs; 24 papers/reports); and led two expert workshops (n = 11). RESULTS: Interventions that raise the price of cheaper shop-bought alcohol appear promising as 'sweetspot' policies; any impact on hospitality is likely small and potentially positive. Restrictions on online sales such as speed or timing of delivery may reduce harm and diversion of consumption from on-trade to home settings. Place-shaping is not well-supported by evidence and experts were sceptical. Reduced late-night trading hours likely reduce violence; evidence of impact on hospitality is scant. Other violence reduction initiatives may modestly reduce harms whilst supporting hospitality, but require resources to deliver multiple measures simultaneously in partnership. CONCLUSIONS: Available evidence and expert views point to regulation of pricing and online sales as having greatest potential as 'sweetspot' alcohol policies, reducing alcohol harm whilst minimising negative impact on hospitality businesses.

Knowledge exchange in crisis settings: A scoping review.

BACKGROUND: Public health practice and efforts to improve the social determinants of health operate within a climate characterised by multiple and intersecting crises. This includes the Covid-19 pandemic as well as more protracted crises such as climate change and persistent social inequalities that impact health. We sought to understand and compare how knowledge exchange (KE) processes occur across different crises, and how knowledge on improving social determinants of health can be utilised at times of crisis to reduce health inequalities and strengthen public systems. METHODS: We conducted a scoping review to understand how KE on improving social determinants of health can occur across different types of crises (e.g. environmental, pandemics, humanitarian). Relevant studies were identified through electronic searching of Medline, EMBASE, Global Health, Scopus and Web of Science databases. RESULTS: We identified 86 studies for inclusion in the review. Most studies concerned pandemic or environmental crises. Fewer studies explored KE during technical (e.g. nuclear), terror-related or humanitarian crises. This may reflect a limitation of the searches. Few studies assessed KE as part of longer-term responses to social and economic impacts of crises, with studies more likely to focus on immediate response or early recovery stages. Exchange of research evidence or data with policy or practice contextual knowledge was common but there was variation in the extent that lay (public) knowledge was included as part of KE processes. CONCLUSION: As ongoing crises continue with significant public health implications, KE processes should appropriately reflect the complexity inherent in crises and foreground health inequalities. Doing so could include the utilisation of systems or complexity-informed methods to support planning and evaluation of KE, a greater focus on KE to support action to address social determinants of health, and the inclusion of a plurality of knowledge-including lived experience-in planning and responding to crises.

How Do Industry-Funded Alcohol and Gambling Conferences Frame the Issues? An Analysis of Conference Agendas.

OBJECTIVE: There is a growing evidence base that unhealthy commodity industries (including alcohol and gambling) promote industry-favorable framings of product harms and solutions. These framings adopt a focus on the individual while overlooking broader influences and solutions. One potential method to influence the framing of harms and solutions is funding and organizing conferences. This study aims to examine how industry-funded alcohol and gambling conferences present themselves and frame product harms and solutions. METHOD: We conducted a descriptive examination and framing analysis of industry-funded alcohol and gambling conference descriptions and agendas or programs to examine how conferences were presented. We also examined how the included topics framed the issues of product harm and solutions. A hybrid approach (using both deductive and inductive coding) was used for framing analysis, informed by previous research. RESULTS: All the included conferences were targeted at professionals outside of the respective industry, many specifically mentioning researchers or policy makers. Several of the conferences offered professional credits for attendance. We identified four key frames that are consistent with the existing evidence base: a complex link between product consumption and harm, focus on the individual, deflection from population-level approaches, and medicalization/specialization of solutions. CONCLUSIONS: We found industry-favorable framings of harms and solutions within the alcohol and gambling conferences included in our sample. These conferences are aimed at professionals outside of the industry, including researchers and policy makers, with several offering professional credits for attendance. Greater awareness of the potential for industry-favorable framings at conference settings is required.

Systems Thinking and Complexity Science Methods and the Policy Process in Non-communicable Disease Prevention: A Systematic Scoping Review.

BACKGROUND: Given the complex determinants of non-communicable diseases (NCDs), and the dynamic policy landscape, researchers and policymakers are exploring the use of systems thinking and complexity science (STCS) in developing effective policies. The aim of this review is to systematically identify and analyse existing applications of STCS-informed methods in NCD prevention policy. METHODS: Systematic scoping review: We searched academic databases (Medline, Scopus, Web of Science, EMBASE) for all publications indexed by 13 October 2020, screening titles, abstracts and full texts and extracting data according to published guidelines. We summarised key data from each study, mapping applications of methods informed by STCS to policy process domains. We conducted a thematic analysis to identify advantages, limitations, barriers and facilitators to using STCS. RESULTS: 4681 papers were screened and 112 papers were included in this review. The most common policy areas were tobacco control, obesity prevention and physical activity promotion. Methods applied included system dynamics modelling, agent-based modelling and concept mapping. Advantages included supporting evidence-informed decision-making; modelling complex systems and addressing multi-sectoral problems. Limitations included the abstraction of reality by STCS methods, despite aims of encompassing greater complexity. Challenges included resource-intensiveness; lack of stakeholder trust in models; and results that were too complex to be comprehensible to stakeholders. Ensuring stakeholder ownership and presenting findings in a user-friendly way facilitated STCS use. CONCLUSION: This review maps the proliferating applications of STCS methods in NCD prevention policy. STCS methods have the potential to generate tailored and dynamic evidence, adding robustness to evidence-informed policymaking, but must be accessible to policy stakeholders and have strong stakeholder ownership to build consensus and change stakeholder perspectives. Evaluations of whether, and under what circumstances, STCS methods lead to more effective policies compared to conventional methods are lacking, and would enable more targeted and constructive use of these methods.

Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review.

Introduction: Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption. Methods: A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each. Results: 366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences. Conclusion: NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Addressing alcohol-related harms in the local night-time economy: a qualitative process evaluation from a complex systems perspective.

OBJECTIVES: English local authorities (LAs) are interested in reducing alcohol-related harms and may use discretionary powers such as the Late Night Levy (LNL) to do so. This study aims to describe how system stakeholders hypothesise the levy may generate changes and to explore how the system, its actors and the intervention adapt and co-evolve over time. DESIGN: A process evaluation from a complex systems perspective, using qualitative methods. SETTING: A London LA with high densities of residential and commercial properties, which implemented the LNL in 2014. PARTICIPANTS: Data were generated through interviews with LNL implementers and alcohol consumers, observations in bars and during LNL patrols and documentary review. INTERVENTION: The LNL allows LAs to charge late-night alcohol retailers an annual fee (£299-£4440) to manage and police the night-time economy (NTE). RESULTS: When the LNL was being considered, stakeholders from different interest groups advanced diverse opinions about its likely impacts while rarely referencing supporting research evidence. Proponents of the levy argued it could reduce crime and anti-social behaviour by providing additional funds to police and manage the NTE. Critics of the levy hypothesised adverse consequences linked to claims that the intervention would force venues to vary their hours or close, cluster closing times, reduce NTE diversity and undermine public-private partnerships. In the first 2 years, levy-funded patrols developed relationships with the licensed trade and the public. The LNL did not undermine public-private partnerships and while some premises varied their hours, these changes did not undermine the intervention's viability, nor significantly cluster venue closing times, nor obviously damage the area's reputation for having a diverse NTE. CONCLUSIONS: This study applies a framework for process evaluation from a complex systems perspective. The evaluation could be extended to measure alcohol-related outcomes and to consider the interplay between the national and local systems.

Feed Composition and Isolate of Histomonas meleagridis Alter Horizontal Transmission of Histomonosis in Turkeys. Proof of Concept.

Outbreaks of histomonosis in turkeys are typically initiated by the ingestion of contaminated embryonated eggs of Heterakis gallinarum, potentially present in earthworms and mechanical vectors. Once an outbreak is started, infected turkeys can transmit the disease by horizontal transmission. Factors influencing horizontal transmission of histomonosis are poorly understood. Replication of horizontal transmission in experimental conditions has not been consistent, presenting an obstacle in searching for alternatives to prevent or treat the disease. Two pilot experiments and three validation experiments were conducted in the present study. In pilot experiment 1, one isolate of Histomonas meleagridis (named Buford) was used. Turkeys were fed a low-nutrient density diet corn-soy based (LOW-CS) and raised in floor pens. In pilot experiment 2, another isolate of H. meleagridis was used (named PHL). Turkeys were fed a low-nutrient density diet with the addition of wheat middlings (LOW-WM) and raised in floor pens. In experiment 3, conducted on floor pens, both isolates and diets were used in different groups. In experiment 4, turkeys were raised on battery cages and only the PHL isolate was used. Both diets (LOW-WM and LOW-CS) were used, in addition to a diet surpassing the nutritional needs of young poults (turkey starter, TS). In experiment 5, conducted in battery cages, only the PHL isolate was used, and the LOW-WM and TS diets were in different groups. The horizontal transmission was achieved only with the PHL isolate from all experiments. The transmission rate varied among experimental diets, with the TS diet having the lowest transmission rate in experiments 4 and 5. Variation was observed between experiments and within experimental groups.

Applying a Systems Perspective to Preventive Health: How Can It Be Useful? Comment on "What Can Policy-Makers Get Out of Systems Thinking? Policy Partners' Experiences of a Systems-Focused Research Collaboration in Preventive Health".

Advocates suggest that a paradigm shift in preventive health towards systems thinking is desirable and may be underway. In a recent study of policy-makers' opinions, Haynes and colleagues found a mixed response to an Australian initiative that sought to apply systems theories and associated methods to preventive health. Some were enthusiastic about systems, but others were concerned or unconvinced about its usefulness. This commentary responds to such concerns. We argue that a systems perspective can help provide policy-makers with timely evidence to inform decisions about intervention planning and delivery. We also suggest that research applying a systems perspective could provide policy-makers with evidence to support planning and incremental decision-making; make recommendations to support intervention adaptability; consider potential barriers due to incoherent systems, and consider the political consequences of interventions.

Systems thinking and complexity science methods and the policy process in non-communicable disease prevention: a systematic scoping review protocol.

INTRODUCTION: Given the complex causal origins of many non-communicable diseases (NCDs), and the complex landscapes in which policies designed to tackle them are made and unfold, the need for systems thinking and complexity science (STCS) in developing effective policy solutions has been emphasised. While numerous methods informed by STCS have been applied to the policy process in NCD prevention, these applications have not been systematically catalogued. The aim of this scoping review is to identify existing applications of methods informed by STCS to the policy process for NCD prevention, documenting which domains of the policy process they have been applied to. METHODS AND ANALYSIS: A systematic scoping review methodology will be used. IDENTIFICATION: We will search Medline, SCOPUS, Embase and Web of Science using search terms combining STCS, NCD prevention and the policy process. All records published in English will be eligible for inclusion, regardless of study design. SELECTION: We will screen titles and abstracts and extract data according to published guidelines for scoping reviews. In order to determine the quality of the included studies, we will use the approach developed by Dixon-Woods et al, excluding studies identified as fatally flawed, and determining the credibility and contribution of included studies. SYNTHESIS: We will identify relevant studies, summarising key data from each study and mapping applications of methods informed by STCS to different parts of the policy process. Review findings will provide a useful reference for policy-makers, outlining which domains of the policy process different methods have been applied to. ETHICS AND DISSEMINATION: Formal ethical approval is not required, as the study does not involve primary data collection. The findings of this study will be disseminated through a peer-reviewed publication, presentations and summaries for key stakeholders.

Applying a complex systems perspective to alcohol consumption and the prevention of alcohol-related harms in the 21st century: a scoping review.

BACKGROUND AND AIMS: A complex systems perspective has been advocated to explore multi-faceted factors influencing public health issues, including alcohol consumption and associated harms. This scoping review aimed to identify studies that applied a complex systems perspective to alcohol consumption and the prevention of alcohol-related harms in order to summarize their characteristics and identify evidence gaps. METHODS: Studies published between January 2000 and September 2020 in English were located by searching for terms synonymous with 'complex systems' and 'alcohol' in the Scopus, MEDLINE, Web of Science and Embase databases, and through handsearching and reference screening of included studies. Data were extracted on each study's aim, country, population, alcohol topic, system levels, funding, theory, methods, data sources, time-frames, system modifications and type of findings produced. RESULTS: Eighty-seven individual studies and three systematic reviews were identified, the majority of which were conducted in the United States or Australia in the general population, university students or adolescents. Studies explored types and patterns of consumption behaviour and the local environments in which alcohol is consumed. Most studies focused on individual and local interactions and influences, with fewer examples exploring the relationships between these and regional, national and international subsystems. The body of literature is methodologically diverse and includes theory-led approaches, dynamic simulation models and social network analyses. The systematic reviews focused on primary network studies. CONCLUSIONS: The use of a complex systems perspective has provided a variety of ways of conceptualizing and analyzing alcohol use and harm prevention efforts, but its focus ultimately has remained on predominantly individual- and/or local-level systems. A complex systems perspective represents an opportunity to address this gap by also considering the vertical dimensions that constrain, shape and influence alcohol consumption and related harms, but the literature to date has not fully captured this potential.

Evaluation of public health interventions from a complex systems perspective: A research methods review.

INTRODUCTION: Applying a complex systems perspective to public health evaluation may increase the relevance and strength of evidence to improve health and reduce health inequalities. In this review of methods, we aimed to: (i) classify and describe different complex systems methods in evaluation applied to public health; and (ii) examine the kinds of evaluative evidence generated by these different methods. METHODS: We adapted critical review methods to identify evaluations of public health interventions that used systems methods. We conducted expert consultation, searched electronic databases (Scopus, MEDLINE, Web of Science), and followed citations of relevant systematic reviews. Evaluations were included if they self-identified as using systems- or complexity-informed methods and if they evaluated existing or hypothetical public health interventions. Case studies were selected to illustrate different types of complex systems evaluation. FINDINGS: Seventy-four unique studies met our inclusion criteria. A framework was developed to map the included studies onto different stages of the evaluation process, which parallels the planning, delivery, assessment, and further delivery phases of the interventions they seek to inform; these stages include: 1) theorising; 2) prediction (simulation); 3) process evaluation; 4) impact evaluation; and 5) further prediction (simulation). Within this framework, we broadly categorised methodological approaches as mapping, modelling, network analysis and 'system framing' (the application of a complex systems perspective to a range of study designs). Studies frequently applied more than one type of systems method. CONCLUSIONS: A range of complex systems methods can be utilised, adapted, or combined to produce different types of evaluative evidence. Further methodological innovation in systems evaluation may generate stronger evidence to improve health and reduce health inequalities in our complex world.

Implications of a complexity perspective for systematic reviews and guideline development in health decision making.

There is growing interest in the potential for complex systems perspectives in evaluation. This reflects a move away from interest in linear chains of cause-and-effect, towards considering health as an outcome of interlinked elements within a connected whole. Although systems-based approaches have a long history, their concrete implications for health decisions are still being assessed. Similarly, the implications of systems perspectives for the conduct of systematic reviews require further consideration. Such reviews underpin decisions about the implementation of effective interventions, and are a crucial part of the development of guidelines. Although they are tried and tested as a means of synthesising evidence on the effectiveness of interventions, their applicability to the synthesis of evidence about complex interventions and complex systems requires further investigation. This paper, one of a series of papers commissioned by the WHO, sets out the concrete methodological implications of a complexity perspective for the conduct of systematic reviews. It focuses on how review questions can be framed within a complexity perspective, and on the implications for the evidence that is reviewed. It proposes criteria which can be used to determine whether or not a complexity perspective will add value to a review or an evidence-based guideline, and describes how to operationalise key aspects of complexity as concrete research questions. Finally, it shows how these questions map onto specific types of evidence, with a focus on the role of qualitative and quantitative evidence, and other types of information.

Shared decision-making and outcomes in type 2 diabetes: A systematic review and meta-analysis.

OBJECTIVE: Type 2 diabetes is a chronic disease which necessitates the development of a therapeutic alliance between patient and provider. This review systematically examines the association between treatment shared decision-making (SDM) and outcomes in diabetes. METHODS: A range of bibliographic databases and gray literature sources was searched. Included studies were subjected to dual data extraction and quality assessment. Outcomes were synthesized using meta-analyses where reporting was sufficiently homogenous or alternatively synthesized in narrative fashion. RESULTS: The search retrieved 4592 records, which were screened by title, abstract, and full text to identify 16 studies with a range of study designs and populations. We found evidence of an association between SDM and improved decision quality, patient knowledge and patient risk perception. We found little evidence of an association between SDM and glycemic control, patient satisfaction, quality of life, medication adherence or trust in physician. CONCLUSIONS: This work elucidates the potential clinical utility of SDM interventions in the management of Type 2 Diabetes and helps inform future research on the topic. PRACTICE IMPLICATIONS: A more complete understanding of the associations between SDM and outcomes will guide and motivate efforts aimed at improving uptake of the SDM paradigm.

Consequences of removing cheap, super-strength beer and cider: a qualitative study of a UK local alcohol availability intervention.

OBJECTIVES: Increasingly, English local authorities have encouraged the implementation of an intervention called 'Reducing the Strength' (RtS) whereby off-licences voluntarily stop selling inexpensive 'super-strength' (≥6.5% alcohol by volume (ABV)) beers and ciders. We conceptualised RtS as an event within a complex system in order to identify pathways by which the intervention may lead to intended and unintended consequences. DESIGN: A qualitative study including a focus group and semistructured interviews. SETTING: An inner-London local authority characterised by a high degree of residential mobility, high levels of social inequality and a large homeless population. Intervention piloted in three areas known for street drinking with a high alcohol outlet density. PARTICIPANTS: Alcohol service professionals, homeless hostel employees, street-based services managers and hostel dwelling homeless alcohol consumers (n=30). RESULTS: Participants describe a range of potential substitution behaviours to circumvent alcohol availability restrictions including consuming different drinks, finding alternative shops, using drugs or committing crimes to purchase more expensive drinks. Service providers suggested the intervention delivered in this local authority missed opportunities to encourage engagement between the council, alcohol services, homeless hostels and off-licence stores. Some participants believed small-scale interventions such as RtS may facilitate new forms of engagement between public and private sector interests and contribute to long-term cultural changes around drinking, although they may also entrench the view that 'problem drinking' only occurs in certain population groups. CONCLUSIONS: RtS may have limited individual-level health impacts if the target populations remain willing and able to consume alternative means of intoxication as a substitute for super-strength products. However, RtS may also lead to wider system changes not directly related to the consumption of super-strengths and their assumed harms.

Does Shared Decision Making in Cancer Treatment Improve Quality of Life? A Systematic Literature Review.

BACKGROUND: The growing consensus espousing the use of shared decision making (SDM) in cancer treatment has coincided with the rise of health care evaluation paradigms that emphasize quality of life (QOL) as a central outcome measure. This review systematically examines the association between treatment SDM and QOL outcomes in cancer. METHODS: A range of bibliographic databases and gray literature sources was searched. The search retrieved 16,726 records, which were screened by title, abstract, and full text to identify relevant studies. The review included 17 studies with a range of study designs and populations. Data were extracted on study methods, participants, setting, study or intervention description, outcomes, main findings, secondary findings, and limitations. Quality appraisal was used, in conjunction with a narrative approach, to synthesize the evidence. RESULTS: The review found weak, but suggestive, evidence for a positive association between perceived patient involvement in decision making, a central dimension of SDM, and QOL outcomes in cancer. The review did not find evidence for an inverse association between SDM and QOL. The poor methodological quality and heterogeneity of the extant literature constrained the derived conclusions. In addition, the literature commonly treated various subscales of QOL instruments as separate outcomes, increasing the probability of spurious findings. CONCLUSIONS: There is weak evidence that aspects of shared decision-making approaches are positively associated with QOL outcomes and very little evidence of a negative association. The extant literature largely assessed patient involvement, only capturing one aspect of the shared decision-making construct, and is of poor quality, necessitating robust studies examining the association.