Brett Maclennan

Non-response bias in a community survey of drinking, alcohol-related experiences and public opinion on alcohol policy

BACKGROUND The continuing decline in response rates to household surveys is a concern for the health and social sciences as it increases the risk of selective non-response biasing the estimates of interest. METHODS We analysed non-response bias in a postal survey measuring drinking behaviour, experience of harm and opinion on local government alcohol policies among residents in six New Zealand communities. The Continuum of Resistance model, which suggests that late respondents to a survey are most similar to non-respondents on the measures of interest, was used to guide our investigation. RESULTS Men, younger people, those of Māori descent and those living in more deprived areas were less likely to respond to our survey than women, older people, those not of Māori descent and those living in comparatively affluent areas. Late respondents more closely resembled non-respondents demographically than early respondents. The prevalence of binge drinking and experience of assault was higher, and support for restrictive local government alcohol policies lower, among late respondents. Assuming the drinking behaviour and alcohol-related experiences of non-respondents were the same as those of late respondents, prevalence was under-estimated by 3.4% (relative difference: 13%) and 2.1% (relative difference: 21%) for monthly binge drinking and assault respectively. Policy support was not over-estimated. CONCLUSION The findings add to a growing body of evidence suggesting that surveys under-estimate risk behaviour because of selective non-response and this bias increases as response rates fall. Notably, public opinion may not be subject to such misestimation.

Local government alcohol policy development: case studies in three New Zealand communities

Aims Local alcohol policies can be effective in reducing alcohol-related harm. The aim of this study was to examine local government responses to alcohol-related problems and identify factors influencing their development and adoption of alcohol policy. Designsettings and participants Case studies were used to examine local government responses to alcohol problems in three New Zealand communities: a rural town, a provincial city and a metropolitan city. Newspaper reports, local government documents and key informant interviews were used to collect data which were analysed using two conceptual frameworks: Kingdons Streams model and the Stakeholder model of policy development. Measurements Key informant narratives were categorized according to the concepts of the Streams and Stakeholder models. Findings Kingdons theoretical concepts associated with increased likelihood of policy change seemed to apply in the rural and metropolitan communities. The political environment in the provincial city, however, was not favourable to the adoption of alcohol restrictions. The Stakeholder model highlighted differences between the communities in terms of power over agenda-setting and conflict between politicians and bureaucrats over policy solutions to alcohol-related harm. These differences were reflected in the ratio of policies considered versus adopted in each location. Decisions on local alcohol policies lie ultimately with local politicians, although the policies that can be adopted by local government are restricted by central government legislation. Conclusions The adoption of policies and strategies to reduce alcohol-related harm may be better facilitated by an agenda-setting process where no ‘gate-keepers’ determine what is included into the agenda, and community mobilization efforts to create competitive local government elections around alcohol issues. Policy adoption would also be facilitated by more enabling central government legislation.

Twelve‐month post‐injury outcomes for Māori and non‐Māori: findings from a New Zealand cohort study

Objective: To examine the prevalence of key outcomes among Māori and non‐Māori 12 months post‐injury, and to estimate the risk of these outcomes for Māori compared to non‐Māori.

Changes in awareness of cancer risk factors among adult New Zealanders (CAANZ): 2001 to 2015

Behaviour change, specifically that which decreases cancer risk, is an essential element of cancer control. Little information is available about how awareness of risk factors may be changing over time. This study describes the awareness of cancer risk behaviours among adult New Zealanders in two cross-sectional studies conducted in 2001 and 2014/5.Telephone interviews were conducted in 2001 (n = 436) and 2014/5 (n = 1064). Participants were asked to recall things they can do to reduce their risk of cancer. They were then presented with a list of potential risk behaviours and asked if these could increase or decrease cancer risk.Most New Zealand adults could identify at least one action they could take to reduce their risk of cancer. However, when asked to provide specific examples, less than a third (in the 2014/5 sample) recalled key cancer risk reduction behaviours such as adequate sun protection, physical activity, healthy weight, limiting alcohol and a diet high in fruit. There had been some promising changes since the 2001 survey, however, with significant increases in awareness that adequate sun protection, avoiding sunbeds/solaria, healthy weight, limiting red meat and alcohol, and diets high in fruit and vegetables decrease the risk of developing cancer.

Public participation in local alcohol regulation: Findings from a survey of New Zealand communities

INTRODUCTION AND AIMS In many high-income countries, the responsibility for alcohol regulation is being devolved from central to local governments. Although seeking public input is typically required by law, there remains little empirical evidence on whether and how the public is involved. We investigated public participation in local liquor licensing and related regulation in New Zealand. DESIGN AND METHODS In 2007, we randomly sampled 2337 residents from the national electoral roll in seven communities and invited them to complete a postal questionnaire assessing their level of general community engagement, whether they had taken action on alcohol issues, and barriers to participation they perceived or encountered. RESULTS A total of 1372 individuals responded (59% response). Fifty-two percent were current members of community organisations, and 40% had ever taken action on a local issue. Respondents considered alcohol to be a major problem locally, but only 4% had been involved in action to address a problem, whereas 18% had considered taking action. In their communities, 12% and 24%, respectively, felt they could influence the number or location of alcohol outlets. There was little variation across communities. DISCUSSION AND CONCLUSION Despite high levels of general community engagement and alcohol being widely regarded as a local problem, few community members reported acting on alcohol issues, and their self-efficacy to effect change was low.

Public opinion and local government alcohol policy: a study of seven New Zealand communities

In democratic political systems one would expect public opinion to be a primary determinant of social policy, yet there are numerous examples of discordance between prevailing opinions and government activity. We sought to assess the extent of agreement between public opinion and local government alcohol policies in New Zealand communities during a period of substantial public and political focus on alcohol-related harm. In 2007, we measured public support for various alcohol policies using a cross-sectional postal survey. Local government documents were examined and council staff interviewed to determine the presence or absence of a range of alcohol-related harm countermeasures. Public support was compared with policy status (present vs. absent) in each community. Agreement varied from moderate in a metropolitan city to total in the two rural areas. Despite the majority of residents supporting policies that research suggests would reduce alcohol-related harm, in most communities, and particularly the largest metropolitan area, local government policy did not always reflect public opinion.

Alcohol-attributable cancer deaths under 80 years of age in New Zealand.

INTRODUCTION AND AIMS Cancer deaths made up 30% of all alcohol-attributable deaths in New Zealanders aged 15-79 years in 2007, more than all other chronic diseases combined. We aimed to estimate alcohol-attributable cancer mortality and years of life lost by cancer site and identify differences between Māori and non-Māori New Zealanders. DESIGN AND METHODS We applied the World Health Organizations comparative risk assessment methodology at the level of Māori and non-Māori subpopulations. Proportions of specific alcohol-related cancers attributable to alcohol were calculated by combining alcohol consumption estimates from representative surveys with relative risks from recent meta-analyses. These proportions were applied to both 2007 and 2012 mortality data. RESULTS Alcohol consumption was responsible for 4.2% of all cancer deaths under 80 years of age in 2007. An average of 10.4 years of life was lost per person; 12.7 years for Māori and 10.1 years for non-Māori. Half of the deaths were attributable to average consumption of <4 standard drinks per day. Breast cancer comprised 61% of alcohol-attributable cancer deaths in women, and more than one-third of breast cancer deaths were attributable to average consumption of <2 standard drinks per day. Mortality data from 2012 produced very similar findings. DISCUSSION AND CONCLUSIONS Alcohol is an important and modifiable cause of cancer. Risk of cancer increases with higher alcohol consumption, but there is no safe level of drinking. Reduction in population alcohol consumption would reduce cancer deaths. Additional strategies to reduce ethnic disparities in risk and outcome are needed in New Zealand. [Connor J, Kydd R, Maclennan B, Shield K, Rehm J. Alcohol-attributable cancer deaths under 80 years of age in New Zealand. Drug Alcohol Rev 2017;36:415-423].

Commentary on Melson et al. (2011): pluralistic ignorance is probably real but important questions remain about its relation to drinking and role in intervention.

Many studies, mostly involving US college students, ostensibly show that young people tend to believe that more of their peers engage in heavy episodic drinking [1], illicit drug use [2] and risky sex [3] than actually do so. College students are also found to misperceive injunctive norms, thinking that their peers are more permissive of certain risk behaviours than they really are [4]. These errors of judgement have been framed in terms of pluralistic ignorance [4], described as a phenomenon in which ‘a majority of group members privately reject a norm, but assume (incorrectly) that most others accept it’ [5]. Given the tendency for over-estimation of behavioural and injunctive norms to be positively correlated with the subject’s own risk behaviour (e.g. heavier drinkers tend to over-estimate their peers’ drinking more than moderate drinkers [6]), norm misperceptions are a potentially important target of intervention. To be effective this approach requires individual behaviour to be at least in part caused by norm misperception, e.g. by drinking to fit in with peers. Programs to correct norm misperceptions have become almost synonymous with prevention on US college campuses [7] and have been used in some other countries [8], the rationale being that heavy drinkers will adjust their behaviour to align more closely with actual norms [9]. In addition to this broadcast approach, in which a whole campus or group is subject to a marketing campaign, several individually focused interventions rely on the provision of normative feedback and correction of norm misperceptions by clinicians [10] or computer programs [11]. The pervasiveness of these interventions makes the hypothesis posed by Melson et al. [12] provocative and important, namely, that norm misperceptions are merely artefacts of the way data are collected rather than real errors of judgement. They suggest that by providing reports of perceived peer behaviour and attitudes alongside reports of their own behaviour and attitudes, respondents are prompted to cast themselves in a favourable light compared with peers. Melson and colleagues randomised Scottish secondary school students to answer a ‘multiple-target’ questionnaire (including both selfand peer-referent items) or ‘single-target’ questionnaires, containing either self-referent or peer-referent items. They find no difference in responses to frequency of consumption and intoxication measures between the multiple-target condition and either of the single-target conditions, i.e. no evidence of artefact in relation to perceived behavioural norms. The critical finding was that those responding to the multiple-target questionnaire judged their peers to have more liberal attitudes toward alcohol than those randomised to the single-target peerreferent questionnaire. The finding is limited by possible ordering effects (acknowledged by the authors), and generalisability is limited by the sample’s youth relative to most research on this topic. The findings arguably support the notion that apparent pluralistic ignorance of injunctive norms, but not behavioural norms, is partly due to the way we ask the questions. The paper raises important issues regarding the widespread use of social norm interventions despite a lack of high quality studies demonstrating their effectiveness [13] and particular studies suggesting their ineffectiveness [14,15]. Furthermore, social norm interventions may displace more effective interventions. In a study of 747 US college campuses, Wechsler and colleagues found that campuses employing social norm programs were less likely to implement effective policies such as restricting alcohol availability on campus, than were campuses that did not employ social norms interventions [15]. It is critical to note the differences, both theoretical and empirical, between broadcast normative feedback and personalised interventions, where the message can be individually tailored. In the broadcast approach the influence may be harmful particularly if students believe they can safely increase their alcohol consumption to meet the norm. Is it responsible to broadcast the norm where the norm is unhealthy? At some New Zealand universities, hazardous drinking is the norm, with more than 60% of students classifiable as hazardous drinkers on the basis of their AUDIT scores [16]. In the personalised approach, for which empirical evidence is promising [13], messages are tailored to optimise the motivational effect of normative information on the individual. For example, with a patient whose drinking exceeds the norm for episodic drinking but not weekly consumption, a common scenario among college students, only the episodic normative feedback is provided (e.g. [17]). While the broadcast approach is appealing because of the potential for mass dissemination, with information technology it is possible to provide individualised intervention to students at numerous, entire campuses simultaneously [18]. If misperception of injunctive norms (i.e. thinking others are more permissive of risky drinking than they actually are) is a driver of drinking behaviour, and the degree or prevalence of misperception is less than COMMENTARY

Hazardous Drinking among Students over a Decade of University Policy Change: Controlled Before-and-After Evaluation

Background: Responding to high levels of alcohol-related harm among students, a New Zealand university deployed a security and liaison service, strengthened the Student Code of Conduct, increased its input on the operation of alcohol outlets near campus, and banned alcohol advertising on campus. We estimated the change in the prevalence of alcohol consumption patterns among students at the university compared with other universities. Methods: We conducted a controlled before-and-after study with surveys in residential colleges at the target university in 2004 and 2014, and in random samples of students at the target university and three control universities in 2005 and 2013. The primary outcome was the prevalence of recent intoxication, while we analysed drinking per se and drinking in selected locations to investigate mechanisms of change. Results: The 7-day prevalence of intoxication decreased from 45% in 2004 to 33% in 2014 (absolute difference: 12%; 95% CI: 7% to 17%) among students living in residential colleges, and from 40% in 2005 to 26% in 2013 (absolute difference: 14%; 95% CI: 8% to 20%) in the wider student body of the intervention university. The intervention effect estimate, representing the change at the intervention university adjusted for change at other universities (aOR = 1.30; 95% CI: 0.89 to 1.90), was consistent with a benefit of intervention but was not statistically significant (p = 0.17). Conclusion: In this period of alcohol policy reform, drinking to intoxication decreased substantially in the targeted student population. Policy reforms and coincidental environmental changes may each have contributed to these reductions.

Predictors of Work Participation for Māori Three Months After Injury

ABSTRACT An important rehabilitation outcome for injured Māori is a timely sustainable return to work. This article identifies the factors influencing working after injury in an attempt to reduce the individual, social, and economic costs. Māori participants in the Prospective Outcomes of Injury Study were interviewed about preinjury and injury-related factors. Among Māori participants, 521 were working for pay prior to injury; 64% were working 3 months postinjury. Factors identified, using modified Poisson regression, that predicted working include financial security (aRR = 1.34, 95% CI [1.12, 1.61]), an injury of low (aRR = 1.76, 95% CI [1.26, 2.44]) or moderate severity (aRR = 1.86, 95% CI [1.34, 2.59]), professional occupations (aRR = 1.22, 95% CI [1.03, 1.44]), and jobs with less repetitive hand movement (aRR = 1.17, 95% CI [1.01, 1.34]). These factors identified warrant attention when planning interventions to enable rehabilitation back to the workplace.