Fred Martineau

Population-level interventions to reduce alcohol-related harm: An overview of systematic reviews

OBJECTIVE To analyse available review-level evidence on the effectiveness of population-level interventions in non-clinical settings to reduce alcohol consumption or related health or social harm. METHOD Health, social policy and specialist review databases between 2002 and 2012 were searched for systematic reviews of the effectiveness of population-level alcohol interventions on consumption or alcohol-related health or social outcomes. Data were extracted on review research aim, inclusion criteria, outcome indicators, results, conclusions and limitations. Reviews were quality-assessed using AMSTAR criteria. A narrative synthesis was conducted overall and by policy area. RESULTS Fifty-two reviews were included from ten policy areas. There is good evidence for policies and interventions to limit alcohol sale availability, to reduce drink-driving, to increase alcohol price or taxation. There is mixed evidence for family- and community-level interventions, school-based interventions, and interventions in the alcohol server setting and the mass media. There is weak evidence for workplace interventions and for interventions targeting illicit alcohol sales. There is evidence of the ineffectiveness of interventions in higher education settings. CONCLUSION There is a pattern of support from the evidence base for regulatory or statutory enforcement interventions over local non-regulatory approaches targeting specific population groups.

The evolution of global health teaching in undergraduate medical curricula.

BackgroundSince the early 1990s there has been a burgeoning interest in global health teaching in undergraduate medical curricula. In this article we trace the evolution of this teaching and present recommendations for how the discipline might develop in future years.DiscussionUndergraduate global health teaching has seen a marked growth over the past ten years, partly as a response to student demand and partly due to increasing globalization, cross-border movement of pathogens and international migration of health care workers. This teaching has many different strands and types in terms of topic focus, disciplinary background, the point in medical studies in which it is taught and whether it is compulsory or optional.We carried out a survey of medical schools across the world in an effort to analyse their teaching of global health. Results indicate that this teaching is rising in prominence, particularly through global health elective/exchange programmes and increasing teaching of subjects such as globalization and health and international comparison of health systems. Our findings indicate that global health teaching is moving away from its previous focus on tropical medicine towards issues of more global relevance.We suggest that there are three types of doctor who may wish to work in global health – the ‘globalised doctor’, ‘humanitarian doctor’ and ‘policy doctor’ – and that each of these three types will require different teaching in order to meet the required competencies. This teaching needs to be inserted into medical curricula in different ways, notably into core curricula, a special overseas doctor track, optional student selected components, elective programmes, optional intercalated degrees and postgraduate study.SummaryWe argue that teaching of global health in undergraduate medical curricula must respond to changing understandings of the term global health. In particular it must be taught from the perspective of more disciplines than just biomedicine, in order to reflect the social, political and economic causes of ill health. In this way global health can provide valuable training for all doctors, whether they choose to remain in their countries of origin or work abroad.

Responsibility without legal authority? Tackling alcohol-related health harms through licensing and planning policy in local government

Background The power to influence many social determinants of health lies within local government sectors that are outside public healths traditional remit. We analyse the challenges of achieving health gains through local government alcohol control policies, where legal and professional practice frameworks appear to conflict with public health action. Methods Current legislation governing local alcohol control in England and Wales is reviewed and analysed for barriers and opportunities to implement effective population-level health interventions. Case studies of local government alcohol control practices are described. Results Addressing alcohol-related health harms is constrained by the absence of a specific legal health licensing objective and differences between public health and legal assessments of the relevance of health evidence to a specific place. Local governments can, however, implement health-relevant policies by developing local evidence for alcohol-related health harms; addressing cumulative impact in licensing policy statements and through other non-legislative approaches such as health and non-health sector partnerships. Innovative local initiatives—for example, minimum unit pricing licensing conditions—can serve as test cases for wider national implementation. Conclusions By combining the powers available to the many local government sectors involved in alcohol control, alcohol-related health and social harms can be tackled through existing local mechanisms.

Engaging 'communities': anthropological insights from the West African Ebola epidemic.

The recent Ebola epidemic in West Africa highlights how engaging with the sociocultural dimensions of epidemics is critical to mounting an effective outbreak response. Community engagement was pivotal to ending the epidemic and will be to post-Ebola recovery, health system strengthening and future epidemic preparedness and response. Extensive literatures in the social sciences have emphasized how simple notions of community, which project solidarity onto complex hierarchies and politics, can lead to ineffective policies and unintended consequences at the local level, including doing harm to vulnerable populations. This article reflects on the nature of community engagement during the Ebola epidemic and demonstrates a disjuncture between local realities and what is being imagined in post-Ebola reports about the lessons that need to be learned for the future. We argue that to achieve stated aims of building trust and strengthening outbreak response and health systems, public health institutions need to reorientate their conceptualization of ‘the community’ and develop ways of working which take complex social and political relationships into account. This article is part of the themed issue ‘The 2013–2016 West African Ebola epidemic: data, decision-making and disease control’.

Epistemologies of Ebola: Reflections on the Experience of the Ebola Response Anthropology Platform

ABSTRACT:By September 2014, it was clear that conventional approaches to containing the spread of Ebola in West Africa were failing. Public health teams were often met with fear, and efforts to treat patients and curtail population movement frequently backfired. Both governments and international agencies recognized that anthropological expertise was essential if locally acceptable, community-based interventions to interrupt transmission were to be designed. The Ebola Response Anthropology Platform was established against this background. Drawing together local and internationally based anthropologists, the Platform provided a coordinated and rapid response to the outbreak in real time. This social thought & commentary piece explores how the Platform developed and interacted with other epistemic communities to produce knowledge and policy over the course of the outbreak. Reflecting on the experiences of working with the UK Department for International Development, the World Health Organization, and other agencies, we ask: what do these experiences reveal about the politics of (expert) knowledge and its influence on the design and implementation of policy? Did differing conceptions of the place of anthropology in humanitarian crises by policymakers and practitioners shape the contributions made by the Ebola Response Anthropology Platform? What are the implications of these experiences for future anthropological engagement with, and research on, humanitarian responses to health crises?

People-centred health systems: building more resilient health systems in the wake of the Ebola crisis.

Abstract The 2014–2016 West African Ebola outbreak demonstrated the extent to which local social and political dynamics shape health system responses to crises such as epidemics. Many post-Ebola health system strengthening programmes are framed around a notion of health system ‘resilience’ that focuses on global rather than local priorities and fails to account for key local social dynamics that shape crisis responses. Post-crisis health system strengthening efforts require a shift towards a more ‘people-centred’ understanding of resilience that attends to the people, relationships and local contexts that constitute health systems and the practices that produce crisis responses.

PP71 Cultures of Evidence Among Decision-Makers in Non-Health Fields: Systematic Review of Qualitative Evidence

Background Many non-health public policy sectors which form part of local government may have impacts on population health outcomes. Decision-makers’ views about research evidence, and their practices of evidence use, are less well understood in these sectors than in healthcare or public health. Methods Systematic review (PRISMA) of qualitative evidence. A range of sources were searched. Studies were included if: they included local policy-makers or practitioners in transport, housing, urban planning and regeneration, crime and policing, or licensing; and reported substantive data on views, beliefs or experiences regarding research evidence. Study findings were synthesised using a grounded-theory thematic analysis approach. Results A range of contextual factors impact on evidence use, including personal contacts, institutional structures and power relationships, and national legal or policy constraints. Academic research evidence is often a relatively small part of the overall knowledge base for decision-making. The types of evidence used vary considerably across sectors: evaluations of effectiveness are generally a secondary concern, with descriptive evidence on contexts being more highly valued. General messages about the value of evidence-based policy and practice have been widely disseminated, and some sectors report relatively high rates of evidence use. However, decision-makers’ understandings of these messages are highly divergent, and the ways evidence is used in practice often do not conform to academic researchers’ preconceptions. Discussion Compared to healthcare or public health, cultures of evidence in non-health sectors present distinct issues. The findings of this review indicate the need for a broader perspective on evidence use, which takes into account the whole decision-making process, and the interaction of academic research with more informal and situated forms of knowledge. Linear models of ‘knowledge translation’ may not capture the complexity of potential relations between knowledge and practice, and the wide variation in decision-makers’ understandings of the concept of evidence.