The effectiveness of adolescent-specific prenatal interventions on improving attendance and reducing harm during and after birth: a systematic review.

BACKGROUND: Adolescent pregnancy has been associated with poor pregnancy outcomes including pre-term birth (PTB), low birth weight (LBW) and perinatal death. OBJECTIVE: To systematically review the effect of adolescent-specific interventions on reducing PTB, LBW, and perinatal death and increasing prenatal care attendance. SEARCH STRATEGY: Possible studies for inclusion were identified by a comprehensive search of OvidSP MEDLINE (limits: humans, 1990-present), EMBASE (limits: humans, 1990-2015), Popline and Global Health Database from the World Health Organisation (WHO) and PubMed International scientific databases, and references of identified articles were searched from 1990 to present. SELECTION CRITERIA: All types of controlled studies of prenatal interventions were exclusive to adolescents and at least one of the outcomes of interest. DATA COLLECTION AND ANALYSIS: Investigators identified relevant studies and entered the data in a pro forma. Data were summarised as forest plots and narrative synthesis. MAIN RESULTS: Twenty-two studies (three randomised controlled trials (RCTs), four prospective cohort studies, nine retrospective cohort studies, five case controls and one natural experiment) were included with all but one study being carried out in higher-income countries. Seven of the 16 studies reporting on PTB found a statistically significant reduction in PTB rates between adolescent-specific prenatal care (intervention) and non-age specific prenatal care odds ratio (OR) and 95% confidence intervals (CIs) ranged from OR: 0.15 (95% CI: 0.03-0.83) to OR: 0.59 (95% CI: 0.45-0.78). Nine of the 12 studies reported statistically significant higher mean prenatal attendance rates among the intervention group compared to controls (ranging from a mean number of visits of 14.3 vs. 10.7 p<0.001 to 10.8 vs. 7.6 visits p<0.001). The type and construct of the interventions, their implementation and local population differed sufficiently that a statistical synthesis was deemed inappropriate. CONCLUSION: There is some evidence that adolescent-specific programs can increase prenatal attendance and reduce the risk of PTB and low birth rate but their effect on perinatal death is uncertain. There is a distinct lack of evidence of the effectiveness of these interventions for adolescents living in low-middle income countries, despite having the majority of adolescent pregnancies, and associated risk of harm. No high-quality intervention studies were identified. Robust, cluster-based RCTs are an urgent necessity to quantify the impact of these interventions and to identify factors contributing to their success.

Can a dietary quality score derived from a short-form FFQ assess dietary quality in UK adult population surveys?

OBJECTIVE: To devise a measure of diet quality from a short-form FFQ (SFFFQ) for population surveys. To validate the SFFFQ against an extensive FFQ and a 24 h diet recall. DESIGN: Population-based cross-sectional survey. SETTING: East Leeds and Bolton in Northern England. SUBJECTS: Adults (n 1999) were randomly selected from lists of those registered with a general practitioner in the study areas, contacted by mail and asked to complete the SFFFQ. Responders were sent a longer FFQ to complete and asked if they would take part in a telephone-based 24 h diet recall. RESULTS: Results from 826 people completing the SFFFQ, 705 completing the FFQ and forty-seven completing the diet recall were included in the analyses. The dietary quality score (DQS), based on fruit, vegetable, oily fish, non-milk extrinsic sugar and fat intakes, showed significant agreement between the SFFFQ and the FFQ (κ=0·38, P<0·001). The DQS for the SFFFQ and the diet recall did not show significant agreement (κ=0·04, P=0·312). A number of single items on the SFFFQ predicted a 'healthy' DQS when calculated from the FFQ. The odds of having a healthy diet were increased by 27 % (95 % CI 9, 49 %, P<0·001) for an increase in fruit of 1 portion/d and decreased by 67 % (95 % CI 47, 79 %, P<0·001) for an increase in crisps of 1 portion/d. CONCLUSIONS: The SFFFQ has been shown to be an effective method of assessing diet quality. It provides an important method for determining variations in diet quality within and across different populations.

The effect of using different competence frameworks to audit the content of a masters program in public health.

OBJECTIVES: (1) To quantify the effect of using different public health competence frameworks to audit the curriculum of an online distance learning MPH program, and (2) to measure variation in the outcomes of the audit depending on which competence framework is used. STUDY DESIGN: Retrospective audit. METHODS: We compared the teaching content of an online distance learning MPH program against each competence listed in different public health competence frameworks relevant to an MPH. We then compared the number of competences covered in each module in the program's teaching curriculum and in the program overall, for each of the competence frameworks used in this audit. RESULTS: A comprehensive search of the literature identified two competence frameworks specific to MPH programs and two for public health professional/specialty training. The number of individual competences in each framework were 32 for the taught aspects of the UK Faculty of Public Health Specialist Training Program, 117 for the American Association of Public Health, 282 for the exam curriculum of the UK Faculty of Public Health Part A exam, and 393 for the European Core Competencies for MPH Education. This gave a total of 824 competences included in the audit. Overall, the online MPH program covered 88-96% of the competences depending on the specific framework used. This fell when the audit focused on just the three mandatory modules in the program, and the variation between the different competence frameworks was much larger. CONCLUSION: Using different competence frameworks to audit the curriculum of an MPH program can give different indications of its quality, especially as it fails to capture teaching considered to be relevant, yet not included in an existing competence framework. The strengths and weaknesses of using competence frameworks to audit the content of an MPH program have largely been ignored. These debates are vital given that external organizations responsible for accreditation specify a particular competence framework to be used. Our study found that each of four different competence frameworks suggested different levels of quality in our teaching program, at least in terms of the competences included in the curriculum. Relying on just one established framework missed some aspects of the curriculum included in other frameworks used in this study. Conversely, each framework included items not covered by the others. Thus, levels of agreement with the content of our MPH and established areas of competence were, in part, dependent on the competence framework used to compare its' content. While not entirely a surprising finding, this study makes an important point and makes explicit the challenges of selecting an appropriate competence framework to inform MPH programs, and especially one which recruits students from around the world.

Population Impact Analysis: a framework for assessing the population impact of a risk or intervention.

BACKGROUND: To describe an organizing framework, Population Impact Analysis, for applying the findings of systematic reviews of public health literature to estimating the impact on a local population, with the aim of implementing evidence-based decision-making. METHODS: A framework using population impact measures to demonstrate how resource allocation decisions may be influenced by using evidence-based medicine and local data. An example of influenza vaccination in the over 65s in Trafford to reduce hospital admissions for chronic obstructive pulmonary disease (COPD) is used. RESULTS: The number of COPD admissions due to non-vaccination of the over 65 in Trafford was 16.4 (95% confidence interval: 13.5; 19.5) and if vaccination rates were taken up to 90%, 11.5 (95% confidence interval: 9.3; 13.8) admissions could have been prevented. A total of 705 (95% confidence interval: 611; 861) people would have to be vaccinated against influenza to prevent one hospital admission. CONCLUSIONS: Population Impact Analysis can help the 'implementation' aspect of evidence for population health. It has been developed to support public health policy makers at both local and national/international levels in their role of commissioning services.

Cigarette smoking and primary open angle glaucoma: a systematic review.

PURPOSE: To evaluate the epidemiologic evidence for a causal association between tobacco smoking and primary open angle glaucoma (POAG). METHODS: Systematic review, including quality assessment, of published analytical epidemiologic studies and evaluation of the evidence using established causality criteria (strength, consistency, temporality, dose response, reversibility, and biologic plausibility). RESULTS: Eleven papers describing 9 case-control studies, 1 prospective cohort study, and a paper describing a pooled analysis based on 2 prospective cohort studies were included in the review. The methodologic quality of most included studies was poor. The strongest studies methodologically were the cohort studies on which the pooled analysis was based. Neither the prospective cohort study (rate ratio not reported) nor the pooled analysis of 2 prospective cohort studies (adjusted rate ratio 0.9) found an association between smoking and POAG. There was a significant positive association between smoking and POAG in only 2 of the case-control studies (adjusted odds ratio 2.9 and 10.8). There was no evidence of a dose-response relationship with smoking or of reversibility of effect in the studies where this was assessed. CONCLUSIONS: This systematic review provided little evidence for a causal association between smoking and development of POAG. Given the limited evidence from high quality studies, and the possibility that flaws in many of the studies reviewed biased the results toward the null, further high quality research to confirm our conclusions is needed. However, it remains important to warn ophthalmic patients of the dangers of smoking and provide cessation support owing to the clear evidence of links between smoking and other ocular and systemic diseases.

Should we encourage over-the-counter statins? A population perspective for coronary heart disease prevention.

BACKGROUND: Prescribed statin therapy has contributed to a dramatic reduction in primary and secondary coronary heart disease (CHD). In the UK, simvastatin is currently available without prescription; however, the US FDA rejected an application for nonprescription lovastatin in 2005. OBJECTIVE AND METHODS: We used population impact measures for three hypothetical levels of CHD risk to estimate the number of CHD events that would be prevented in the US over 5 years under three scenarios: (i) prescription-only regulations; (ii) approval of over-the-counter (OTC) statins; and (iii) implementation of lifestyle interventions. RESULTS: For people at very low risk of CHD, 429,299 CHD events could be prevented by the availability of OTC statins and 560,243 CHD events could be prevented among this group by implementing lifestyle interventions. For those at moderate risk of CHD, 244,388 CHD events could be prevented by OTC statins compared with 318 866 by lifestyle interventions. For people at high risk of CHD, prescription statins could prevent 374,897 CHD events over the next 5 years. CONCLUSIONS: Provision of OTC statins to US adults at low or moderate risk of CHD would have a greater impact on CHD prevention than providing prescription statins for those at high risk of CHD. Provision of OTC statins alongside lifestyle interventions among those at low or moderate risk of CHD could substantially reduce the number of CHD events in the population.

'Smoke gets in your eyes': a research-informed professional education and advocacy programme.

Smoking is associated with common sight-threatening eye conditions. We suspected that this link was little known and it might be a potent novel health promotional tool. We therefore developed a programme ultimately aiming to reduce the burden of eye disease attributable to smoking. The programme aims were to (1) raise awareness of the link between smoking and eye disease and advocate changes in relevant policies and (2) investigate and promote change in professional practice so that smokers are identified and routinely offered smoking cessation advice/support in eyecare settings. An inter-professional team developed a programme of research and education targeting policy-makers, healthcare professionals, the public and patients. We reviewed evidence about the causal link between smoking and eye disease, researched current awareness of the link, researched current practice of eyecare health professionals, produced health education materials and campaigned for policy changes. The series of projects was completed successfully, achieving media coverage, confirming the causal link between smoking and eye disease and demonstrating low awareness of this association. Healthcare leaders and policy-makers were engaged in our programme resulting in commitment, in principle, from the UK's Chief Medical Officer and the European Commission to consider including warning labels related to blindness on cigarette packets.

Teenagers' perceptions of blindness related to smoking: a novel message to a vulnerable group.

BACKGROUND: Cigarette smoking often starts in teenage years. It is not known whether teenagers are aware of the association of smoking with eye disease and blindness. AIM: To explore the knowledge of the link between smoking, and eye diseases and blindness, and the likely impact of this knowledge among teenagers in UK. METHODS: A cross-sectional survey, using a structured interview of teenagers attending four organised social events, was conducted. Awareness and fear of blindness, and of three smoking-related diseases (lung cancer, heart disease and stroke) and a distractor condition (deafness) was investigated. The likelihood of smokers quitting on developing early signs of each condition was determined. RESULTS: A 92% "opt in" response rate was achieved. Out of 260 teenagers (16-18 years), 15%, 27% and 81% believed that smoking caused stroke, heart disease and lung cancer, respectively. Only 5% believed smoking caused blindness. Subjects ranked their fear of each of the five conditions, scoring five for the most feared and one for the least feared. Subjects were significantly (p<0.01) more fearful (mean scores in brackets) of blindness (4.2) than of lung cancer (3.4), heart disease (2.3) and deafness (1.2). More teenagers (p<0.01) said they would stop smoking on developing early signs of blindness compared with early signs of lung or heart disease. CONCLUSIONS: Awareness of the risk of blindness from smoking is low among teenagers, but fear of blindness may be more likely to motivate teenagers to stop smoking than fear of lung or heart disease. Teenagers should be made more aware of the ocular risks of cigarette smoking as a novel public health measure.

The population effect of crime and neighbourhood on physical activity: an analysis of 15,461 adults.

Area-based interventions offer the potential to increase physical activity for many sedentary people in countries such as the UK. Evidence on the effect of individual and area/neighbourhood influences on physical activity is in its infancy, and despite its value to policy makers a population focus is rarely used. Data from a population-based health and lifestyle survey of adults in northwest England were used to analyse associations between individual and neighbourhood perceptions and physical activity. The population effect of eliminating a risk factor was expressed as a likely effect on population levels of physical activity. Of the 15,461 responders, 21,923 (27.1%) were physically active. Neighbourhood perceptions of leisure facilities were associated with physical activity, but no association was found for sense of belonging, public transport or shopping facilities. People who felt safe in their neighbourhood were more likely to be physically active, but no associations were found for vandalism, assaults, muggings or experience of crime. The number of physically active people would increase by 3290 if feelings of "unsafe" during the day were removed, and by 11,237 if feelings of "unsafe" during the night were removed. An additional 8342 people would be physically active if everyone believed that they were "very well placed for leisure facilities". Feeling safe had the potential largest effect on population levels of physical activity. Strategies to increase physical activity in the population need to consider the wider determinants of health-related behaviour, including fear of crime and safety.

Risks and benefits of omega 3 fats for mortality, cardiovascular disease, and cancer: systematic review.

OBJECTIVE: To review systematically the evidence for an effect of long chain and shorter chain omega 3 fatty acids on total mortality, cardiovascular events, and cancer. DATA SOURCES: Electronic databases searched to February 2002; authors contacted and bibliographies of randomised controlled trials (RCTs) checked to locate studies. REVIEW METHODS: Review of RCTs of omega 3 intake for (3) 6 months in adults (with or without risk factors for cardiovascular disease) with data on a relevant outcome. Cohort studies that estimated omega 3 intake and related this to clinical outcome during at least 6 months were also included. Application of inclusion criteria, data extraction, and quality assessments were performed independently in duplicate. RESULTS: Of 15,159 titles and abstracts assessed, 48 RCTs (36,913 participants) and 41 cohort studies were analysed. The trial results were inconsistent. The pooled estimate showed no strong evidence of reduced risk of total mortality (relative risk 0.87, 95% confidence interval 0.73 to 1.03) or combined cardiovascular events (0.95, 0.82 to 1.12) in participants taking additional omega 3 fats. The few studies at low risk of bias were more consistent, but they showed no effect of omega 3 on total mortality (0.98, 0.70 to 1.36) or cardiovascular events (1.09, 0.87 to 1.37). When data from the subgroup of studies of long chain omega 3 fats were analysed separately, total mortality (0.86, 0.70 to 1.04; 138 events) and cardiovascular events (0.93, 0.79 to 1.11) were not clearly reduced. Neither RCTs nor cohort studies suggested increased risk of cancer with a higher intake of omega 3 (trials: 1.07, 0.88 to 1.30; cohort studies: 1.02, 0.87 to 1.19), but clinically important harm could not be excluded. CONCLUSION: Long chain and shorter chain omega 3 fats do not have a clear effect on total mortality, combined cardiovascular events, or cancer.

Unsung heroes who put their lives at risk? Informal caring, health and neighbourhood attachment.

BACKGROUND: Previous studies have highlighted the effects of informal caring on mental health, but evidence for its wider impact remains scant. We explored associations between informal care and a range of health (and health-related) measures. We also considered previously neglected differences between informal care 'at home' and care elsewhere, along with neighbourhood attachment as a possible modifier of the associations we found. METHODS: The study involved a large population survey in two Primary Care Trusts. Data were collected by postal survey of 15,465 adults; subjects were selected from the local General Practice register. 12.7 per cent of respondents identified themselves as carers. Health measures included psychiatric morbidity, bodily pain, self-assessed health, health-related behaviours, obesity, prescribed drugs and high levels of GP consultation. RESULTS: Of nine measures considered, care at home was associated with psychiatric morbidity (OR 1.46, 95 per cent CI 1.25--1.70), bodily pain (OR 1.19, 95 per cent CI 1.02--1.39), and obesity (OR 1.59, 95 per cent CI 1.34--1.89). Care 'away' was associated with smoking (OR 1.26, 95 per cent CI 1.03--1.54), and inversely with both sedentary living (OR 0.70, 95 per cent CI 0.58--0.85) and poor self-assessed health (OR 0.78, 95 per cent CI 0.62--0.99). Health tended to be poorer when carers lacked a sense of neighbourhood attachment. CONCLUSIONS: Informal carers are likely to face serious health challenges besides anxiety and depression. Caring is associated with several aspects of poor health, which are themselves predictors of premature mortality. Proactive and wide-ranging support is required, the more so in neighbourhoods where carers feel alienated. Research and policy should distinguish carers 'at home' from carers 'away'.

Does primary care referral to an exercise programme increase physical activity one year later? A randomized controlled trial.

OBJECTIVE: To assess the effectiveness of a primary care referral scheme on increasing physical activity at 1 year from referral. Design Two-group randomized controlled trial recruiting primary care referrals to a borough-based exercise scheme. Setting A local authority borough in the north-west of England. Participants 545 patients defined as sedentary by a primary care practitioner. Intervention Referral to a local-authority exercise referral scheme and written information compared with written information only. Main outcome measures Meeting physical activity target at 12 months following referral, with a secondary outcome measured at 6 months from referral. RESULTS: At 12 months, a non-significant increase of 5 per cent was observed in the intervention compared with control group, for participation in at least 90 minutes of moderate/vigorous activity per week (25.8 versus 20.4 per cent, OR 1.45, 0.84 to 2.50, p = 0.18). At 6 months, a 10 per cent treatment effect was observed which was significant (22.6 versus 13.6 per cent, OR 1.67, 1.08 to 2.60, p = 0.05). The intervention increased satisfaction with information but this did not influence adherence with physical activity. CONCLUSION: Community-based physical activity referral schemes have some impact on reducing sedentary behaviour in the short-term, but which is unlikely to be sustained and lead to benefits in terms of health.

Increasing response to a postal survey of sedentary patients - a randomised controlled trial [ISRCTN45665423].

BACKGROUND: A systematic review identified a range of methods, which can influence response rates. However, analysis specific to a healthcare setting, and in particular, involving people expected to be poor responders, was missing, We examined the effect of pre-warning letters on response rates to a postal survey of sedentary patients whom we expected a low rate of response. METHODS: Participants were randomised to receive a pre-warning letter or no pre-warning letter, seven days before sending the main questionnaire. The main questionnaire included a covering letter and pre-paid return envelope. After seven days, non-responders were sent a reminder letter and seven days later, another reminder letter with a further copy of the questionnaire and return envelope. RESULTS: 627 adults, with a mean age of 48 years (SD 13, range 18 to 78) of whom 69.2% (434/627) were women, were randomised. 49.0% (307/627) of patients were allocated to receive a pre-warning letter and 51.0% (320/627) no pre-warning letter, seven days in advance of posting the main questionnaire. The final response rate to the main questionnaire was 30.0% (92/307) amongst those sent a pre-warning letter and 20.9% (67/320) not sent a pre-warning letter, with an adjusted odds ratio of 1.60 (95% CI 1.1, 2.30). CONCLUSIONS: The relatively low cost method of sending a pre-warning letter had a modest impact on increasing response rates to a postal questionnaire sent to a group of patients for whom a low response rate was anticipated. Investigators should consider incorporating this simple intervention when conducting postal surveys, to reduce the potential for nonresponse bias and to increase the study power. Methods other than postal surveys may be needed however when a low response rate to postal surveys is likely.

Who and how many people are taking herbal supplements? A survey of 21,923 adults.

BACKGROUND: There is little information on the number and characteristics of adults taking herbal supplements and the relationship of this with other health and lifestyle factors. These were examined in the current study. METHODS: Information on herbal supplement use and health and lifestyle characteristics was obtained by postal questionnaire, sent to a sample of the adult population in Northwest England. RESULTS: In summer 2001, 70.5% (15,465/21,923) of questionnaires were returned. The mean age of responders was 49.8 years (SD 17.57) and 45.2% (6,986/15,465) were men. The percentage taking at least one herbal supplement was 12.8% (1,987/15,465). Users of herbal supplements were more likely to be younger, female, white, and to own their home. Herbal supplement use was not strongly associated with any health and lifestyle variables examined. Weak associations were found with physical activity, psychiatric caseness, and use of prescribed medications. The most common herbal supplement was evening primrose oil, taken by 7.7% (1,186/15,465) of respondents (12.7% of women and 1.1% of men). CONCLUSIONS: More than one in ten adults were taking herbal supplements, with evening primrose oil, the most common supplement, used mainly by women. Individual characteristics such as age, sex, ethnicity, and social class influenced the use of herbal supplements, but there was no evidence that this substituted for conventional medical care. The evidence base to support some popular herbal supplements is weak. Large well-designed trials are needed to quantify the value of herbal supplements to health and well-being.

The role of diet in susceptibility to rheumatoid arthritis: a systematic review.

OBJECTIVE: Many studies have examined the role of diet in the management of established rheumatoid arthritis (RA), warranting several recent reviews. However, none have considered the possible link between diet and the onset of RA in detail. Studies investigated a possible effect of individual components of diet and the development of RA, but the lack of a systematic review means there is no unbiased assessment of the evidence. METHODS: We systematically reviewed studies with comparison groups that examined dietary intake or biological markers prior to the onset of RA. Four electronic databases were searched to identify relevant reports. Six quality criteria were agreed, against which the studies were assessed. The main outcome measure was a diagnosis of RA according to the ARA 1958 or revised ACR 1987 classification criteria. RESULTS: Fourteen reports were included in the review. There was evidence of a protective effect of higher consumption of olive oil, oil-rich fish, fruit, vegetables and beta-cryptoxanthin. Lower serum concentrations of antioxidants were associated with an increased risk of RA in 3 studies. Due to the heterogeneity of study designs and analyses, the results could not be pooled. CONCLUSION: Evidence exists that diet may play a role in the etiology of RA, but it is inconclusive due to the small number of studies available and variation in study design.