Screening and alcohol brief interventions in antenatal care: a realistic evaluation

Background: Prenatal alcohol consumption is one of the leading preventable causes of birth defects, including fetal alcohol syndrome and learning disabilities. Although there is strong evidence of the benefits of screening and alcohol brief interventions (ABIs) in reducing hazardous and harmful drinking among the primary care population, evidence of its effectiveness with the antenatal care population is limited. Nevertheless, the Scottish Government is incorporating an alcohol screening and ABI programme as part of the routine antenatal care provided to women in a bid to protect the health and safety of the unborn child and improve subsequent health and developmental outcomes. This research therefore seeks to increase understanding of the factors that are likely to influence the effectiveness of this recently implemented programme. It also aims to explore the extent to which contemporary issues such as change in guidelines regarding alcohol consumption during pregnancy influences perceptions and attitudes, and the possible implications of these on the screening and ABI delivery. Methods: The study described in this thesis employed a realistic evaluation methodology. Realistic evaluation is a theory-driven approach to investigating social programmes. It is concerned with hypothesising, testing and refining programme theories by exploring the interaction of contexts, mechanisms and outcomes. To identify the relevant screening and ABI programme theories, two separate systematic reviews, a critical review and four face-to-face interviews were undertaken with health policy implementers. The findings were used to construct context, mechanism and outcomes propositions. The propositions were then tested by conducting individual interviews with seventeen pregnant women and fifteen midwives, a further six midwifery team leaders were involved in a focus group discussion. A thematic approach using a hybrid of inductive and deductive coding and theme development informed the qualitative analysis. Results: In the context of uncertainties regarding the threshold of drinking that causes fetal harm, pregnant women reported that screening assessment helped them to reflect on their drinking behaviour and facilitate behaviour change. For women who drank at hazardous and harmful levels before attending the booking appointment, screening and ABI may be helpful in terms of eliciting behaviour change. However, they may not be very beneficial in terms of reducing harm to the fetus as it has been found that drinking during the first trimester poses the most risk to the fetus. Training and resources provided to midwives as part of the screening and ABI programme were found to be facilitating mechanisms that midwives indicated improved their skills and confidence. However, most of the midwives had not subsequently employed the motivational interviewing skills required for the ABI delivery, as many of the pregnant women reported that they reduced or abstained from alcohol consumption once pregnancy was confirmed. The outcome noted was that midwives confidence decreased leading to missed opportunities to appropriately deliver the ABI to eligible women. The small numbers of women being identified for ABI meant midwives rarely delivered the ABI. This negatively influenced midwives attitudes as they then accorded ABI low priority in their workload. Other disenabling mechanisms noted to be hampering the implementation of the screening and ABI initiative included midwives contending with competing priorities at the booking appointments, and the lack of adequate rapport between midwives and pregnant women at the booking appointment to discuss alcohol issues appropriately, leading to women providing socially desirable responses to screening questions. Conclusions: The findings of this study has generated greater explanations of the working of the screening and ABI programme in antenatal care setting and has provided transferable lessons that can be used by others intending to implement similar programmes in other settings

Credibility of subgroup analyses by socioeconomic status in public health intervention evaluations:An underappreciated problem?

There is increasing interest amongst researchers and policy makers in identifying the effect of public health interventions on health inequalities by socioeconomic status (SES). This issue is typically addressed in evaluation studies through subgroup analyses, where researchers test whether the effect of an intervention differs according to the socioeconomic status of participants. The credibility of such analyses is therefore crucial when making judgements about how an intervention is likely to affect health inequalities, although this issue appears to be rarely considered within public health. The aim of this study was therefore to assess the credibility of subgroup analyses in published evaluations of public health interventions. An established set of 10 credibility criteria for subgroup analyses was applied to a purposively sampled set of 21 evaluation studies, the majority of which focussed on healthy eating interventions, which reported differential intervention effects by SES. While the majority of these studies were found to be otherwise of relatively high quality methodologically, only 8 of the 21 studies met at least 6 of the 10 credibility criteria for subgroup analysis. These findings suggest that the credibility of subgroup analyses conducted within evaluations of public health interventions’ impact on health inequalities may be an underappreciated problem. Keywords: Health inequalities, Health inequities, Equity and public health interventions, Policy impact by socioeconomic statu

An Extended Network Model with a Packages Diffusion Process

The dynamics of a packages diffusion process within a selforganized network is analytically studied by means of an extended $f$% -spin facilitated kinetic Ising model (Fredrickson-Andersen model) using a Fock-space representation for the master equation. To map the three component system (active, passive and packages cells) onto a lattice we apply two types of second quantized operators. The active cells correspond to mobile states whereas the passive cells correspond to immobile states of the Fredrickson-Andersen model. An inherent cooperativity is included assuming that the local dynamics and subsequently the local mobilities are restricted by the occupation of neighboring cells. Depending on a temperature-like parameter $h^{-1}$ (interconnectivity) the diffusive process of the packages (information) can be almost stopped, thus we get a well separation of the time regimes and a quasi-localization for the intermediate range at low temperatures.Comment: 13 pages and 1 figur

The Daily Mile:Teachers' perspectives of the barriers and facilitators to the delivery of a school-based physical activity intervention

Objectives Children spend a significant amount of their time in a school environment, often engaged in sedentary activities. The Daily Mile is a physical activity intervention which aims to increase physical activity and fitness in children through the completion of an outdoor teacher-led walk or run during the school day. This study aimed to explore the barriers, facilitators and perceived benefits of the Daily Mile from the perspectives of teachers through the use of qualitative semi-structured interviews. It also aimed to identify important context-specific factors, which might require consideration for those who intend to adopt the Daily Mile. Setting Eight Local Authority primary schools in the City of Edinburgh and East Lothian, UK. Participants Thirteen teachers (eleven women) who teach children in primaries one to seven in a school which delivered the Daily Mile. Results Data were analysed using an interpretative thematic analysis. Teachers were positive and enthusiastic about the Daily Mile and perceived it to be beneficial to children's health and fitness. A number of barriers to participation were identified including inadequate all-weather running surfaces and time constraints in an already full school curriculum. The perceived impact on learning time was identified as a concern for teachers, while other benefits were also identified including increased teacher-child rapport and perceived enhanced classroom concentration levels. Conclusion The Daily Mile appears to be a valuable addition to the school day, however important context-specific barriers to delivery of the Daily Mile exist, which should be considered when implementing the Daily Mile in schools

Adolescents and health-related behaviour:using a framework to develop interventions to support positive behaviours

Abstract Background Experimentation is a natural part of adolescent maturation. In conjunction with increased exposure to behaviours such as alcohol or substance use, and the potentially intensified influence of peer groups, unhealthy behaviour patterns may develop as part of this experimentation. However, the adolescent years also provide considerable opportunity for behaviour to be shaped in positive ways that may improve immediate and longer term health outcomes. A systematic review carried out by the authors concluded that physiological changes during adolescence need to be considered when designing or implementing interventions, due to their influence on health behaviours. The aim of the study is to demonstrate how the six steps in quality intervention development (6SQuID) framework can be used, in conjunction with research or review findings, to inform the development of pilot or feasibility studies. Using the synthesised findings from our adolescent systematic review, we sought to illustrate how adolescent interventions might be designed to target specific health behaviours and augment positive adolescent health outcomes. Methods We applied the 6SQuID framework to the findings from a review of adolescent physiological influences on health behaviour. This involved following the process defined within 6SQuID and applying the sequential steps to build a proposed pilot study, based on the pre-defined findings of our systematic review. We used the Social Learning Theory to assist in identifying how and why change can be influenced, with and for adolescents. Results We devised a pilot study example, targeting teaching assistants, to illustrate how the detailed steps within the 6SQuID framework can assist the development and subsequent implementation of adolescent interventions that are likely to be effective. Conclusions This paper gives details of how the 6SQuID framework can be used for intervention development, using specific research findings, across a variety of adolescent health behaviours. This example provides details of how to operationalise 6SQuID in practical terms that are transferrable to other populations and situations. In this respect, we anticipate that this illustrative case may be of use in the design, development, and implementation of a wide variety of interventions