Sexually transmitted infection as a risk factor for homosexual HIV transmission: a systematic review of epidemiological studies

Existing reviews suggest some sexually transmitted infections (STIs) are risk factors in heterosexual HIV transmission. This may not be so in homosexual HIV transmission, about which reviews make no specific conclusions. This paper reviews published studies which report on the relative risk of STIs in HIV seroconversion in homosexually-active men in order to examine this matter. Papers obtained via various searches were judged adequate if they were prospective cohort or cohort-nested case-control studies; used HIV seroconversion as the outcome; assessed STI exposure objectively; and controlled for potential confounding from age and sexual behaviour. Sixteen papers were obtained, of these 3 were judged adequate. Adequate papers reported little association. Inadequate papers were more likely to report association. Evidence from adequate studies does not suggest STIs are risk factors in homosexual HIV transmission. Some caution is needed in interpreting the results because of the paucity of adequate studies

Understanding the development of minimum unit pricing of alcohol in Scotland: A qualitative study of the policy process

Background: Minimum unit pricing of alcohol is a novel public health policy with the potential to improve population health and reduce health inequalities. Theories of the policy process may help to understand the development of policy innovation and in turn identify lessons for future public health research and practice. This study aims to explain minimum unit pricing’s development by taking a ‘multiple-lenses’ approach to understanding the policy process. In particular, we apply three perspectives of the policy process (Kingdon’s multiple streams, Punctuated-Equilibrium Theory, Multi-Level Governance) to understand how and why minimum unit pricing has developed in Scotland and describe implications for efforts to develop evidence-informed policymaking. Methods: Semi-structured interviews were conducted with policy actors (politicians, civil servants, academics, advocates, industry representatives) involved in the development of MUP (n = 36). Interviewees were asked about the policy process and the role of evidence in policy development. Data from two other sources (a review of policy documents and an analysis of evidence submission documents to the Scottish Parliament) were used for triangulation. Findings: The three perspectives provide complementary understandings of the policy process. Evidence has played an important role in presenting the policy issue of alcohol as a problem requiring action. Scotland-specific data and a change in the policy ‘image’ to a population-based problem contributed to making alcohol-related harms a priority for action. The limited powers of Scottish Government help explain the type of price intervention pursued while distinct aspects of the Scottish political climate favoured the pursuit of price-based interventions. Conclusions: Evidence has played a crucial but complex role in the development of an innovative policy. Utilising different political science theories helps explain different aspects of the policy process, with Multi-Level Governance particularly useful for highlighting important lessons for the future of public health policy

Sexually transmitted infection risk exposure among black and minority ethnic youth in northwest London: findings from a study translating a sexually transmitted infection risk-reduction intervention to the UK setting.

OBJECTIVES: Young black women are disproportionately affected by sexually transmitted infections (STI) in the UK, but effective interventions to address this are lacking. The Young Brent Project explored the nature and context of sexual risk-taking in young people to inform the translation of an effective clinic-based STI reduction intervention (Project SAFE) from the USA to the UK. METHODS: One-to-one in-depth interviews (n = 37) and group discussions (n = 10) were conducted among men and women aged 15-27 years from different ethnic backgrounds recruited from youth and genitourinary medicine clinic settings in Brent, London. The interviews explored the context within which STI-related risks were assessed, experienced and avoided, the skills needed to recognise risk and the barriers to behaviour change. RESULTS: Concurrent sexual partnerships, mismatched perceptions and expectations, and barriers to condom use contributed to STI risk exposure and difficulties in implementing risk-reduction strategies. Women attempted to achieve monogamy, but experienced complex and fluid sexual relationships. Low risk awareness, flawed partner risk assessments, negative perceptions of condoms and lack of control hindered condom use. Whereas men made conscious decisions, women experienced persuasion, deceit and difficulty in requesting condom use, particularly with older partners. CONCLUSIONS: Knowledge of STI and condom use skills is not enough to equip young people with the means to reduce STI risk. Interventions with young women need to place greater emphasis on: entering and maintaining healthy relationships; awareness of risks attached to different forms of concurrency and how concurrency arises; skills to redress power imbalances and building self-esteem

How Do Contextual Factors Influence Implementation and Receipt of Positive Youth Development Programs Addressing Substance Use and Violence? A Qualitative Meta-Synthesis of Process Evaluations

Objective:Positive youth development (PYD) often aims to prevent tobacco, alcohol, and drugs use and violence. We systematically reviewed PYD interventions, synthesizing process, and outcomes evidence. Synthesis of outcomes, published elsewhere, found no overall evidence of reducing substance use or violence but notable variability of fidelity. Our synthesis of process evaluations examined how implementation varied and was influenced by context.Data Source:Process evaluations of PYD aiming to reduce substance use and violence.Study Inclusion Criteria:Overall review published since 1985; written in English; focused on youth aged 11 to 18 years; focused on interventions addressing multiple positive assets; reported on theory, process, or outcomes; and concerned with reducing substance use or violence. Synthesis of process evaluations examined how implementation varies with or is influenced by context.Data Extraction:Two reviewers in parallel.Data Synthesis:Thematic synthesis.Results:We identified 12 reports. Community engagement enhanced program appeal. Collaboration with other agencies could broaden the activities offered. Calm but authoritative staff increased acceptability. Staff continuity underpinned diverse activities and durable relationships. Empowering participants were sometimes in tension with requiring them to engage in diverse activities.Conclusion:Our systematic review identified factors that might help improve the fidelity and acceptability of PYD interventions. Addressing these might enable PYD to fulfill its potential as a means of promoting health

The possibility of critical realist randomised controlled trials.

BACKGROUND: Some realists have criticised randomised controlled trials for their inability to explain the causal relations that they identify; to take into account the influence of the social context of the interventions they evaluate; and to account for individual difference. However, among realists, there is controversy over whether it is possible to improve trials by making them realist, or whether realism and the philosophical assumptions underlying trials are incompatible. This paper contributes to the debate in Trials on this issue. The debate thus far has concentrated on the possibility of combining trial methodology with that of realist evaluation. MAIN BODY: We concur with the contention that it is not feasible to combine randomised controlled trial design with the realist evaluation approach. However, we argue that a different variant of realism, critical realism, provides a more appropriate theoretical grounding for realist trials. In contrast to realist evaluation, which regards social mechanisms as an amalgam of social resources and people's reasoning, critical realism insists on their distinction. It does so on the basis of its assertion of the need to distinguish between social structures (in which resources lie) and human agency (which is at least partly guided by reasoning). From this perspective, conceiving of social mechanisms as external to participants can be seen as a valid methodological strategy for supplementing the exclusive concentration of trials on outcomes. While accepting realist evaluation's insistence that causality in open systems involves a configuration of multiple generative mechanisms, we adopt the critical realist interpretation of the experimental method, which sees it as creating artificial closure in order to identify the effects of specific causal mechanisms. If randomised controlled trials can be regarded as epidemiological proxies that substitute probabilistic controls over extraneous factors for closed experiments, their examination of the powers of discrete mechanisms through observation of the variation of outcomes is appropriate. CONCLUSION: While there are still issues to be resolved, critical realist randomised controlled trials are possible and have the potential to overcome some of the difficulties faced by traditional trial designs in accounting for the influence of social context and individual interpretation

Geological structure as a control on floodplain groundwater dynamics

Groundwater in upland floodplains has an important function in regulating river flows and controlling the coupling of hillslope runoff with rivers, with complex interaction between surface waters and groundwaters throughout floodplain width and depth. Heterogeneity is a key feature of upland floodplain hydrogeology and influences catchment water flows, but it is difficult to characterise and therefore is often simplified or overlooked. An upland floodplain and adjacent hillslope in the Eddleston catchment, southern Scotland (UK), has been studied through detailed three-dimensional geological characterisation, the monitoring of ten carefully sited piezometers, and analysis of locally collected rainfall and river data. Lateral aquifer heterogeneity produces different patterns of groundwater level fluctuation across the floodplain. Much of the aquifer is strongly hydraulically connected to the river, with rapid groundwater level rise and recession over hours. Near the floodplain edge, however, the aquifer is more strongly coupled with subsurface hillslope inflows, facilitated by highly permeable solifluction deposits in the hillslope–floodplain transition zone. Here, groundwater level rise is slower but high heads can be maintained for weeks, sometimes with artesian conditions, with important implications for drainage and infrastructure development. Vertical heterogeneity in floodplain aquifer properties, to depths of at least 12 m, can create local aquifer compartmentalisation with upward hydraulic gradients, influencing groundwater mixing and hydrogeochemical evolution. Understanding the geological processes controlling aquifer heterogeneity, which are common to formerly glaciated valleys across northern latitudes, provides key insights into the hydrogeology and wider hydrological behaviour of upland floodplains

The effects of Positive Youth Development interventions on substance use, violence and inequalities:systematic review of theories of change, processes and outcomes

BackgroundPositive Youth Development (PYD) delivered outside school aims to enable young people to develop positive assets such as relationships and confidence, rather than to merely address risk. Existing reviews of PYD effects on substance use or violence are old and unsystematic.ObjectivesTo systematically review evidence to answer the following questions: what theories of change inform PYD interventions addressing substance use and violence? What characteristics of participants and contexts are identified as barriers to and facilitators of implementation and receipt in process evaluations of PYD? What is the effectiveness and cost-effectiveness of PYD in reducing substance use and violence? What characteristics of participants and contexts appear to moderate, or are necessary and sufficient for, PYD effectiveness?Data sourcesA total of 21 bibliographic databases; 35 websites and contacting authors.Review methodsWe included reports published in English since 1985 and reporting on theories of change, as well as process, outcome and economic evaluations of PYD targeting 11- to 18-year-olds and addressing substance use or violence. References were screened on title/abstract and, where appropriate, on full report. Data extraction and quality assessment used Critical Appraisal Skills Programme, Evidence for Policy and Practice Information and Co-ordinating Centre and Cochrane tools. Theories of change and process evaluations were qualitatively metasynthesised. Outcome evaluations were synthesised narratively and meta-analytically.Results32,394 unique references were identified and 48 were included. A total of 16 reports described theories, 13 (10 studies) evaluated processes and 25 (10 studies) evaluated outcomes.Theories of changePYD interventions aim to offer opportunities for young people to develop positive ‘assets’ such as skills and confidence. These are theorised to promote and be promoted by young people’s ‘intentional self-regulation’, which involves reflecting on behaviour; determining goals; using existing resources to pursue these; and redirecting effort when thwarted. This enables ‘developmental regulation’, namely individuals capitalising on other opportunities to promote personal development. Positive assets thus accrued reduce health risks by reducing the impact on individuals of environmental risk or by ameliorating the impact of such risks. The literature offers limited insights beyond these general ideas.Process evaluationsCommunity engagement ensured that programmes were accessible and appealing. Staff capacity and continuity were crucial factors but often challenging when programmes could not offer full-time jobs. Tensions arose between a desire to empower participants to choose activities and a requirement for them to undertake a breadth of activities.Outcome evaluationsMeta-analyses of all combined outcomes and of short-term alcohol use, illicit drug use and smoking found no significant effects. There were small, statistically significant, short-term effects for an omnibus measure of substance use and for violence. We could not undertake metaregression to assess sociodemographic moderators but narrative synthesis suggested no clear pattern of effects by sex. We found no economic evaluations.LimitationsInsufficient studies precluded qualitative comparative analyses.ConclusionsHow PYD might promote health is currently undertheorised. Implementation can be challenging. We found little evidence that current PYD interventions delivered outside school reduce substance use or violence. However, these may not constitute a test of the effectiveness of the PYD model, as some included interventions that, although meeting our inclusion criteria, were not exemplars of PYD.Future workFurther evaluations should assess interventions employing PYD theory of change.Study registrationThis study is registered as PROSPERO CRD42013005439.FundingThe National Institute for Health Research Public Health Research programme

Student- and school-level belonging and commitment and student smoking, drinking and misbehaviour

Objectives: It has been suggested that students are healthier in schools where more students are committed to school. Previous research has examined this only using a proxy measure of value-added education (a measure of whether school-level attendance and attainment are higher than predicted by students’ social profile), finding associations with smoking tobacco, use of alcohol and illicit drugs, and violence. These findings do not provide direct insights into the associations between school-level aggregate student commitment and health behaviours, and may simply reflect the proxy measure being residually confounded by unmeasured student characteristics. We examined the previously used proxy measure of value-added education, as well as direct measures at the level of the school and the student of lack of student commitment to school to see whether these were associated with students’ self-reported smoking tobacco, alcohol use and school misbehaviour. Design: Cross-sectional survey. Setting: A total of 40 schools in south-east England. Methods: Multi-level analyses. Results: There were associations between school- and student-level measures of lack of commitment to school and tobacco smoking, alcohol use and school misbehaviour outcomes, but the proxy measure of school-level commitment, value-added education, was not associated with these outcomes. A sensitivity analysis focused only on violent aspects of school misbehaviour found a pattern of associations identical to that found for the measure of misbehaviour. Conclusion: Our study provides the first direct evidence in support of the Theory of Human Functioning and School Organisation

Socioeconomic differences in the benefits of structured physical activity compared with health education on the prevention of major mobility disability in older adults: the LIFE study.

BACKGROUND: Evidence is lacking on whether health-benefiting community-based interventions differ in their effectiveness according to socioeconomic characteristics. We evaluated whether the benefit of a structured physical activity intervention on reducing mobility disability in older adults differs by education or income. METHODS: The Lifestyle Interventions and Independence for Elders (LIFE) study was a multicentre, randomised trial that compared a structured physical activity programme with a health education programme on the incidence of mobility disability among at-risk community-living older adults (aged 70-89 years; average follow-up of 2.6 years). Education (≤ high school (0-12 years), college (13-17 years) or postgraduate) and annual household income were self-reported (<$24 999,$25 000 to $49 999 and ≥$50 000). The risk of disability (objectively defined as loss of ability to walk 400 m) was compared between the 2 treatment groups using Cox regression, separately by socioeconomic group. Socioeconomic group×intervention interaction terms were tested. RESULTS: The effect of reducing the incidence of mobility disability was larger for those with postgraduate education (0.72, 0.51 to 1.03; N=411) compared with lower education (high school or less (0.93, 0.70 to 1.24; N=536). However, the education group×intervention interaction term was not statistically significant (p=0.54). Findings were in the same direction yet less pronounced when household income was used as the socioeconomic indicator. CONCLUSIONS: In the largest and longest running trial of physical activity amongst at-risk older adults, intervention effect sizes were largest among those with higher education or income, yet tests of statistical interactions were non-significant, likely due to inadequate power. TRIAL REGISTRATION NUMBER: NCT01072500