[Show abstract][Hide abstract] ABSTRACT: Systematic review methods are developing rapidly, and most researchers would recognise their key methodological aspects, such as a closely focussed question, a comprehensive search, and a focus on synthesising 'stronger' rather than 'weaker' evidence. However, it may be helpful to question some of these underlying principles, because while they work well for simpler review questions, they may result in overly narrow approaches to more complex questions and interventions. This commentary discusses some core principles of systematic reviews, and how they may require further rethinking, particularly as reviewers turn their attention to increasingly complex issues, where a Bayesian perspective on evidence synthesis, which would aim to assemble evidence - of different types, if necessary - in order to inform decisions', may be more productive than the 'traditional' systematic review model. Among areas identified for future research are the examination of publication bias in qualitative research; research on the efficiency and potential biases of comprehensive searches in different disciplines; and the use of Bayesian methods in evidence synthesis. The incorporation of a systems perspective into systematic reviews is also an area which needs rapid development.
[Show abstract][Hide abstract] ABSTRACT: Background:
The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between government, industry, and other organisations to improve public health by addressing alcohol, food, health at work, and physical activity. This paper analyses the RD physical activity (PA) pledges in terms of the evidence of their potential effectiveness, and the likelihood that they have motivated actions among organisations that would not otherwise have taken place.
We systematically reviewed evidence of the effectiveness of interventions proposed in four PA pledges of the RD, namely, those on physical activity in the community; physical activity guidelines; active travel; and physical activity in the workplace. We then analysed publically available data on RD signatory organisations' plans and progress towards achieving the physical activity pledges, and assessed the extent to which activities among organisations could be attributed to the RD.
Where combined with environmental approaches, interventions such as mass media campaigns to communicate the benefits of physical activity, active travel in children and adults, and workplace-related interventions could in principle be effective, if fully implemented. However, most activities proposed by each PA pledge involved providing information or enabling choice, which has limited effectiveness. Moreover, it was difficult to establish the extent of implementation of pledges within organisations, given that progress reports were mostly unavailable, and, where provided, it was difficult to ascertain their relevance to the RD pledges. Finally, 15 % of interventions listed in organisations' delivery plans were judged to be the result of participation in the RD, meaning that most actions taken by organisations were likely already under way, regardless of the RD.
Irrespective of the nature of a public health policy to encourage physical activity, targets need to be evidence-based, well-defined, measurable and encourage organisations to go beyond business as usual. RD physical activity targets do not adequately fulfill these criteria.
International Journal of Behavioral Nutrition and Physical Activity 12/2015; 12(1). DOI:10.1186/s12966-015-0264-7 · 4.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is increasing attention on how money may bring about positive changes to health, and money-based development approaches are becoming more commonplace at the 'community' level, including in high-income countries. However, little attention has been paid to how the 'community' might be varyingly conceptualised in these scenarios, or to the potential implications of this for interpreting the impacts of such health improvement approaches. This paper presents a critical interpretive review of literature presenting different scenarios from high-income countries in which the 'community' receives money, to explore how 'community' is conceptualised in relation to this process. Some texts gave explicit definitions of 'community', but multiple other conceptualisations were interpreted across all texts, conveyed through the construction of 'problematics', and descriptions of how and why money was given. The findings indicate that the flow of money shapes how conceptualisations of 'community' are produced, and that the implicit power relations and inequalities can construct and privilege particular sets of identities and relationships throughout the process. This highlights implications for approaching public health evaluations of giving money to 'communities', and for better understanding how it might bring about change to health and inequalities, where the 'community' cannot be interpreted merely as a setting or recipient of such an intervention, but something constructed and negotiated through the flow of money itself.
Social Science [?] Medicine 09/2015; 143:88-97. DOI:10.1016/j.socscimed.2015.08.049 · 2.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
The promotion of health equity, the absence of avoidable and unfair differences in health outcomes, is a global imperative. Systematic reviews are an important source of evidence for health decision-makers, but have been found to lack assessments of the intervention effects on health equity. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) is a 27 item checklist intended to improve transparency and reporting of systematic reviews. We developed an equity extension for PRISMA (PRISMA-E 2012) to help systematic reviewers identify, extract, and synthesise evidence on equity in systematic reviews.
Methods and findings:
In this explanation and elaboration paper we provide the rationale for each extension item. These items are additions or modifications to the existing PRISMA Statement items, in order to incorporate a focus on equity. An example of good reporting is provided for each item as well as the original PRISMA item.
This explanation and elaboration document is intended to accompany the PRISMA-E 2012 Statement and the PRISMA Statement to improve understanding of the reporting guideline for users. The PRISMA-E 2012 reporting guideline is intended to improve transparency and completeness of reporting of equity-focused systematic reviews. Improved reporting can lead to better judgement of applicability by policy makers which may result in more appropriate policies and programs and may contribute to reductions in health inequities.
Journal of clinical epidemiology 09/2015; DOI:10.1016/j.jclinepi.2015.09.001 · 3.42 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Interventions to promote healthy eating make a potentially powerful contribution to the primary prevention of non communicable diseases. It is not known whether healthy eating interventions are equally effective among all sections of the population, nor whether they narrow or widen the health gap between rich and poor. We undertook a systematic review of interventions to promote healthy eating to identify whether impacts differ by socioeconomic position (SEP).
We searched five bibliographic databases using a pre-piloted search strategy. Retrieved articles were screened independently by two reviewers. Healthier diets were defined as the reduced intake of salt, sugar, trans-fats, saturated fat, total fat, or total calories, or increased consumption of fruit, vegetables and wholegrain. Studies were only included if quantitative results were presented by a measure of SEP. Extracted data were categorised with a modified version of the "4Ps" marketing mix, expanded to 6 "Ps": "Price, Place, Product, Prescriptive, Promotion, and Person".
Our search identified 31,887 articles. Following screening, 36 studies were included: 18 "Price" interventions, 6 "Place" interventions, 1 "Product" intervention, zero "Prescriptive" interventions, 4 "Promotion" interventions, and 18 "Person" interventions. "Price" interventions were most effective in groups with lower SEP, and may therefore appear likely to reduce inequalities. All interventions that combined taxes and subsidies consistently decreased inequalities. Conversely, interventions categorised as "Person" had a greater impact with increasing SEP, and may therefore appear likely to reduce inequalities. All four dietary counselling interventions appear likely to widen inequalities. We did not find any "Prescriptive" interventions and only one "Product" intervention that presented differential results and had no impact by SEP. More "Place" interventions were identified and none of these interventions were judged as likely to widen inequalities.
Interventions categorised by a "6 Ps" framework show differential effects on healthy eating outcomes by SEP. "Upstream" interventions categorised as "Price" appeared to decrease inequalities, and "downstream" "Person" interventions, especially dietary counselling seemed to increase inequalities. However the vast majority of studies identified did not explore differential effects by SEP. Interventions aimed at improving population health should be routinely evaluated for differential socioeconomic impact.
BMC Public Health 05/2015; 15(1):457. DOI:10.1186/s12889-015-1781-7 · 2.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Some statements from the Portman Group about our evaluation of the “responsibility deal” on alcohol are seriously misleading.1The statement about our “track record of campaigning against voluntary agreements” is inaccurate. One of our first studies set out to understand the characteristics of effective voluntary agreements,2 which should be based on clearly defined, evidence based, and quantifiable targets; should push partners to go beyond “business as usual”; and should include penalties for not delivering the pledges. Our new findings show that the responsibility deal’s pledges do not meet these criteria.3 4The Portman Group also accuses us of ignoring “official government data showing the achievements of the responsibility deal.” We thoroughly and systematically examined available data provided by partners themselves about their activities, as well as evidence that any of these activities could have a positive impact on public health. Our conclusions were that any impact was likely to be limited, and that organisations had generally signed up to things they were already doing. Our findings regarding the one billion unit pledge support the Sheffield analysis.5The Portman Group also claims that our analyses of the activities of the Alcohol Network “undermine the vital work done to improve public health.” We fail to see how an analysis of whether the responsibility deal alcohol pledges will improve public health can undermine efforts to improve public health.Finally, because alcohol related harms continue to be a major and costly public health problem in England, we restate our conclusions that effective interventions must be at the forefront of any meaningful action and need to go beyond business as usual. The Public Health Responsibility Deal should be first and foremost about improving public health.NotesCite this as: BMJ 2015;350:h2063
[Show abstract][Hide abstract] ABSTRACT: Islamic countries are of key importance to transnational tobacco companies as growing markets with increasing smoking rates. We analyzed internal tobacco industry documents to assess the industry's response to rising concerns about tobacco use within Islamic countries. The tobacco industry perceived Islam as a significant threat to its expansion into these emerging markets. To counter these concerns, the industry framed antismoking views in Islamic countries as fundamentalist and fanatical and attempted to recruit Islamic consultants to portray smoking as acceptable. Tobacco industry lawyers also helped develop theological arguments in favor of smoking. These findings are valuable to researchers and policymakers seeking to implement culturally appropriate measures in Islamic countries under the World Health Organization Framework Convention on Tobacco Control. (Am J Public Health. Published online ahead of print April 16, 2015: e1-e7. doi:10.2105/AJPH.2014.302494).
American Journal of Public Health 04/2015; 105(6):e1-e7. DOI:10.2105/AJPH.2014.302494 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Local government services and policies affect health determinants across many sectors such as planning, transportation, housing and leisure. Researchers and policymakers have argued that decisions affecting wider determinants of health, well-being and inequalities should be informed by evidence. This study explores how information and evidence are defined, assessed and utilised by local professionals situated beyond the health sector, but whose decisions potentially affect health: in this case, practitioners working in design, planning and maintenance of the built environment.
A qualitative study using three focus groups. A thematic analysis was undertaken.
The focus groups were held in UK localities and involved local practitioners working in two UK regions, as well as in Brazil, USA and Canada.
UK and international practitioners working in the design and management of the built environment at a local government level.
Participants described a range of data and information that constitutes evidence, of which academic research is only one part. Built environment decision-makers value empirical evidence, but also emphasise the legitimacy and relevance of less empirical ways of thinking through narratives that associate their work to art and philosophy. Participants prioritised evidence on the acceptability, deliverability and sustainability of interventions over evidence of longer term outcomes (including many health outcomes). Participants generally privileged local information, including personal experiences and local data, but were less willing to accept evidence from contexts perceived to be different from their own.
Local-level built environment practitioners utilise evidence to make decisions, but their view of 'best evidence' appears to prioritise local relevance over academic rigour. Academics can facilitate evidence-informed local decisions affecting social determinants of health by working with relevant practitioners to improve the quality of local data and evaluations, and by advancing approaches to improve the external validity of academic research.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
BMJ Open 04/2015; 5(4):e007053. DOI:10.1136/bmjopen-2014-007053 · 2.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Undernutrition contributes to five million deaths of children under five each year. Furthermore, throughout the life cycle, undernutrition contributes to increased risk of infection, poor cognitive functioning, chronic disease, and mortality. It is thus important for decision-makers to have evidence about the effectiveness of nutrition interventions for young children.
Primary objective1. To assess the effectiveness of supplementary feeding interventions, alone or with co-intervention, for improving the physical and psychosocial health of disadvantaged children aged three months to five years.Secondary objectives1. To assess the potential of such programmes to reduce socio-economic inequalities in undernutrition.2. To evaluate implementation and to understand how this may impact on outcomes.3. To determine whether there are any adverse effects of supplementary feeding.
We searched CENTRAL, Ovid MEDLINE, PsycINFO, and seven other databases for all available years up to January 2014. We also searched ClinicalTrials.gov and several sources of grey literature. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished trials.
Randomised controlled trials (RCTs), cluster-RCTs, controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that provided supplementary food (with or without co-intervention) to children aged three months to five years, from all countries. Adjunctive treatments, such as nutrition education, were allowed. Controls had to be untreated.
Data collection and analysis:
Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data, and assessed risk of bias. We conducted meta-analyses for continuous data using the mean difference (MD) or the standardised mean difference (SMD) with a 95% confidence interval (CI), correcting for clustering if necessary. We analysed studies from low- and middle-income countries and from high-income countries separately, and RCTs separately from CBAs. We conducted a process evaluation to understand which factors impact on effectiveness.
We included 32 studies (21 RCTs and 11 CBAs); 26 of these (16 RCTs and 10 CBAs) were in meta-analyses. More than 50% of the RCTs were judged to have low risk of bias for random selection and incomplete outcome assessment. We judged most RCTS to be unclear for allocation concealment, blinding of outcome assessment, and selective outcome reporting. Because children and parents knew that they were given food, we judged blinding of participants and personnel to be at high risk for all studies.Growth. Supplementary feeding had positive effects on growth in low- and middle-income countries. Meta-analysis of the RCTs showed that supplemented children gained an average of 0.12 kg more than controls over six months (95% confidence interval (CI) 0.05 to 0.18, 9 trials, 1057 participants, moderate quality evidence). In the CBAs, the effect was similar; 0.24 kg over a year (95% CI 0.09 to 0.39, 1784 participants, very low quality evidence). In high-income countries, one RCT found no difference in weight, but in a CBA with 116 Aboriginal children in Australia, the effect on weight was 0.95 kg (95% CI 0.58 to 1.33). For height, meta-analysis of nine RCTs revealed that supplemented children grew an average of 0.27 cm more over six months than those who were not supplemented (95% CI 0.07 to 0.48, 1463 participants, moderate quality evidence). Meta-analysis of seven CBAs showed no evidence of an effect (mean difference (MD) 0.52 cm, 95% CI -0.07 to 1.10, 7 trials, 1782 participants, very low quality evidence). Meta-analyses of the RCTs demonstrated benefits for weight-for-age z-scores (WAZ) (MD 0.15, 95% CI 0.05 to 0.24, 8 trials, 1565 participants, moderate quality evidence), and height-for-age z-scores (HAZ) (MD 0.15, 95% CI 0.06 to 0.24, 9 trials, 4638 participants, moderate quality evidence), but not for weight-for-height z-scores MD 0.10 (95% CI -0.02 to 0.22, 7 trials, 4176 participants, moderate quality evidence). Meta-analyses of the CBAs showed no effects on WAZ, HAZ, or WHZ (very low quality evidence). We found moderate positive effects for haemoglobin (SMD 0.49, 95% CI 0.07 to 0.91, 5 trials, 300 participants) in a meta-analysis of the RCTs.Psychosocial outcomes. Eight RCTs in low- and middle-income countries assessed psychosocial outcomes. Our meta-analysis of two studies showed moderate positive effects of feeding on psychomotor development (SMD 0.41, 95% CI 0.10 to 0.72, 178 participants). The evidence of effects on cognitive development was sparse and mixed.We found evidence of substantial leakage. When feeding was given at home, children benefited from only 36% of the energy in the supplement. However, when the supplementary food was given in day cares or feeding centres, there was less leakage; children took in 85% of the energy provided in the supplement. Supplementary food was generally more effective for younger children (less than two years of age) and for those who were poorer/ less well-nourished. Results for sex were equivocal. Our results also suggested that feeding programmes which were given in day-care/feeding centres and those which provided a moderate-to-high proportion of the recommended daily intake (% RDI) for energy were more effective.
Feeding programmes for young children in low- and middle-income countries can work, but good implementation is key.
[Show abstract][Hide abstract] ABSTRACT: Myths are widely held beliefs and are frequently perpetuated through telling and retelling. We examined 10 myths in public health research and practice. Where possible, we traced their origins, interrogated their current framing in relation to the evidence, and offered possible alternative ways of thinking about them. These myths focus on the nature of public health and public health interventions, and the nature of evidence in public health. Although myths may have some value, they should not be privileged in an evidence-informed public health context. (Am J Public Health. Published online ahead of print February 25, 2015: e1-e5. doi:10.2105/AJPH.2014.302433).
American Journal of Public Health 02/2015; 105(4):e1-e5. DOI:10.2105/AJPH.2014.302433 · 4.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Modifiable lifestyle risk behaviours such as smoking, unhealthy diet, physical inactivity and alcohol misuse are the leading causes of major, non-communicable diseases worldwide. It is increasingly being recognised that interventions which target more than one risk behaviour may be an effective and efficient way of improving people's lifestyles. To date, there has been no attempt to summarise the global evidence base for interventions targeting multiple risk behaviours.
To identify and map the characteristics of studies evaluating multiple risk behaviour change interventions targeted at adult populations in any country.
Seven bibliographic databases were searched between January, 1990, and January/ May, 2013. Authors of protocols, conference abstracts, and other relevant articles were contacted. Study characteristics were extracted and inputted into Eppi-Reviewer 4.
In total, 220 studies were included in the scoping review. Most were randomised controlled trials (62%) conducted in the United States (49%), and targeted diet and physical activity (56%) in people from general populations (14%) or subgroups of general populations (45%). Very few studies had been conducted in the Middle East (2%), Africa (0.5%), or South America (0.5%). There was also a scarcity of studies conducted among young adults (1%), or racial and minority ethnic populations (4%) worldwide.
Research is required to investigate the interrelationships of lifestyle risk behaviours in varying cultural contexts around the world. Cross-cultural development and evaluation of multiple risk behaviour change interventions is also needed, particularly in populations of young adults and racial and minority ethnic populations.
PLoS ONE 01/2015; 10(1):e0117015. DOI:10.1371/journal.pone.0117015 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
[Show abstract][Hide abstract] ABSTRACT: Background
The value placed on types of evidence within decision-making contexts is highly dependent on individuals, the organizations in which the work and the systems and sectors they operate in. Decision-making processes too are highly contextual. Understanding the values placed on evidence and processes guiding decision-making is crucial to designing strategies to support evidence-informed decision-making (EIDM). This paper describes how evidence is used to inform local government (LG) public health decisions.Methods
The study used mixed methods including a cross-sectional survey and interviews. The Evidence-Informed Decision-Making Tool (EvIDenT) survey was designed to assess three key domains likely to impact on EIDM: access, confidence, and organizational culture. Other elements included the usefulness and influence of sources of evidence (people/groups and resources), skills and barriers, and facilitators to EIDM. Forty-five LGs from Victoria, Australia agreed to participate in the survey and up to four people from each organization were invited to complete the survey (n¿=¿175). To further explore definitions of evidence and generate experiential data on EIDM practice, key informant interviews were conducted with a range of LG employees working in areas relevant to public health.ResultsIn total, 135 responses were received (75% response rate) and 13 interviews were conducted. Analysis revealed varying levels of access, confidence and organizational culture to support EIDM. Significant relationships were found between domains: confidence, culture and access to research evidence. Some forms of evidence (e.g. community views) appeared to be used more commonly and at the expense of others (e.g. research evidence). Overall, a mixture of evidence (but more internal than external evidence) was influential in public health decision-making in councils. By comparison, a mixture of evidence (but more external than internal evidence) was deemed to be useful in public health decision-making.Conclusions
This study makes an important contribution to understanding how evidence is used within the public health LG context.Trial registration ACTRN12609000953235.
[Show abstract][Hide abstract] ABSTRACT: Systematic reviews (SRs) are expected to critically appraise included studies and privilege those at lowest risk of bias (RoB) in the synthesis. This study examines if and how critical appraisals inform the synthesis and interpretation of evidence in SRs.
All SRs published in March-May 2012 in 14 high-ranked medical journals and a sample from the Cochrane library were systematically assessed by two reviewers to determine if and how: critical appraisal was conducted; RoB was summarised at study, domain and review levels; and RoB appraisals informed the synthesis process.
Of the 59 SRs studied, all except six (90%) conducted a critical appraisal of the included studies, with most using or adapting existing tools. Almost half of the SRs reported critical appraisal in a manner that did not allow readers to determine which studies included in a review were most robust. RoB assessments were not incorporated into synthesis in one-third (20) of the SRs, with their consideration more likely when reviews focused on randomised controlled trials. Common methods for incorporating critical appraisals into the synthesis process were sensitivity analysis, narrative discussion and exclusion of studies at high RoB. Nearly half of the reviews which investigated multiple outcomes and carried out study-level RoB summaries did not consider the potential for RoB to vary across outcomes.
The conclusions of the SRs, published in major journals, are frequently uninformed by the critical appraisal process, even when conducted. This may be particularly problematic for SRs of public health topics that often draw on diverse study designs.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Journal of Epidemiology & Community Health 12/2014; 69(2). DOI:10.1136/jech-2014-204711 · 3.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The planning profession has been advocated as an untapped resource for obesity prevention, but little is known about how planners view their roles and responsibilities in this area. This paper investigates the role of planners in the Healthy Towns programme in England, and explores the limits and potential for obesity prevention within planning policy and practice. Using a qualitative approach, 23 planning stakeholders were interviewed, identifying the potential for planning in public health, particularly the ‘health proofing’ of local planning policy. National and local governments should better align planning and health policies to support collaboration between planners and public health practitioners.
Health & Place 09/2014; 30:120–126. DOI:10.1016/j.healthplace.2014.08.012 · 2.81 Impact Factor