Lois Orton

Corticosteroids for prevention of mortality in people with tuberculosis: a systematic review and meta-analysis

BACKGROUND The effects of corticosteroids are systemic, but their benefits in tuberculosis are thought to be organ specific, with clinicians using them routinely to treat some forms of tuberculosis (such as meningitis), but not others. We aimed to assess the effects of steroids on mortality attributable to all forms of tuberculosis across organ systems. METHODS We did a systematic review and meta-analysis to estimate the efficacy of steroids for the prevention of mortality in all forms of tuberculosis, and to quantify heterogeneity in this outcome between affected organ systems. We searched the Cochrane Infectious Diseases Group trials register, the Cochrane Central Register of Controlled Trials, Medline, Embase, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) for studies published up to Sept 6, 2012, and checked reference lists of included studies and relevant reviews. We included all trials in people with tuberculosis in any organ system, with tuberculosis defined clinically or microbiologically. There were no restrictions by age, comorbidity, publication language, or type, dose, or duration of steroid treatment. We used the Mantel-Haenszel method to summarise mortality across trials. FINDINGS We identified 41 eligible trials, 18 of which assessed pulmonary tuberculosis. 20 of the 41 trials (including 13 of those for pulmonary tuberculosis) were done before the introduction of modern rifampicin-containing antituberculosis chemotherapy. Meta-analysis stratified by affected organ systems identified no heterogeneity; steroids reduced mortality by 17% (risk ratio [RR] 0·83, 95% CI 0·74-0·92; I(2) 0%), consistent across all organ groups. In a sensitivity analysis that only included trials that used rifampicin-containing regimens, the results were similar (RR 0·85, 95% CI 0·74-0·98; I(2) 21%). A sensitivity analysis in pulmonary tuberculosis that excluded trials with high potential risks of bias suggested a slight benefit, but the point estimate was closer to no effect and the difference was not significant (RR 0·93, 95% CI 0·60-1·44). INTERPRETATION Steroids could be effective in reducing mortality for all forms of tuberculosis, including pulmonary tuberculosis. However, further evidence is needed since few recent trials have assessed the effectiveness of corticosteroids in patients with pulmonary tuberculosis. FUNDING UK Department for International Development.

Are interventions to promote healthy eating equally effective for all? Systematic review of socioeconomic inequalities in impact.

Background: 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). Methods: 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”. Results: 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. Conclusions: 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.

Barriers to partnership working in public health: a qualitative study.

Background Public health provision in England is undergoing dramatic changes. Currently established partnerships are thus likely to be significantly disrupted by the radical reforms outlined in the Public Health White Paper. We therefore explored the process of partnership working in public health, in order to better understand the potential opportunities and threats associated with the proposed changes. Methodology/Principal Findings 70 participants took part in an in-depth qualitative study involving 40 semi-structured interviews and three focus group discussions. Participants were senior and middle grade public health decision makers working in Primary Care Trusts, Local Authorities, Department of Health, academia, General Practice and Hospital Trusts and the third sector in England. Despite mature arrangements for partnership working in many areas, and much support for joint working in principle, many important barriers exist. These include cultural issues such as a lack of shared values and language, the inherent complexity of intersectoral collaboration for public health, and macro issues including political and resource constraints. There is particular uncertainty and anxiety about the future of joint working relating to the availability and distribution of scarce and diminishing financial resources. There is also the concern that existing effective collaborative networks may be completely disrupted as the proposed changes unfold. The extent to which the proposed reforms might mitigate or potentiate these issues remains unclear. However the threats currently remain more salient than opportunities. Conclusions The current re-organisation of public health offers real opportunity to address some of the barriers to partnership working identified in this study. However, significant threats exist. These include the breakup of established networks, and the risk of cost cutting on effective public health interventions.

Group-based microfinance for collective empowerment: a systematic review of health impacts

Abstract Objective To assess the impact on health-related outcomes, of group microfinance schemes based on collective empowerment. Methods We searched the databases Social Sciences Citation Index, Embase, MEDLINE, MEDLINE In-Process, PsycINFO, Social Policy & Practice and Conference Proceedings Citation Index for articles published between 1 January 1980 and 29 February 2016. Articles reporting on health impacts associated with group-based microfinance were included in a narrative synthesis. Findings We identified one cluster-randomized control trial and 22 quasi-experimental studies. All of the included interventions targeted poor women living in low- or middle-income countries. Some included a health-promotion component. The results of the higher quality studies indicated an association between membership of a microfinance scheme and improvements in the health of women and their children. The observed improvements included reduced maternal and infant mortality, better sexual health and, in some cases, lower levels of interpersonal violence. According to the results of the few studies in which changes in empowerment were measured, membership of the relatively large and well-established microfinance schemes generally led to increased empowerment but this did not necessarily translate into improved health outcomes. Qualitative evidence suggested that increased empowerment may have contributed to observed improvements in contraceptive use and mental well-being and reductions in the risk of violence from an intimate partner. Conclusion Membership of the larger, well-established group-based microfinance schemes is associated with improvements in some health outcomes. Future studies need to be designed to cope better with bias and to assess negative as well as positive social and health impacts.

Putting context centre stage: evidence from a systems evaluation of an area based empowerment initiative in England

Abstract It is now widely accepted that context matters in evaluations of the health inequalities impact of community-based social initiatives. Systems thinking offers a lens for uncovering the dynamic relationship between such initiatives and their social contexts. However, there are very few examples that show how a systems approach can be applied in practice and what kinds of evidence are produced when this happens. In this paper, we use data from ethnographic fieldwork embedded within a multi-site mixed method evaluation to demonstrate how a systems approach can be applied in practice to evaluate the early stages of an area-based empowerment initiative – Big Local (funded by the Big Lottery Fund and delivered by Local Trust). Taking place in 150 different local areas in England and underpinned by an ethos of resident-led collective action, Big Local offers an illustration of the applicability of a systems approach to better understand the change processes that emerge as social initiatives embed and co-evolve within a series of local contexts. Findings reveal which parts of the social system are likely to be changed, by what mechanisms, and with what implications. They also raise some salient considerations for knowledge generation and methods development in public health evaluation, particularly for the evaluation of social initiatives where change does not necessarily happen in linear or predictable ways. We suggest future evaluations of such initiatives require the use of more flexible designs, encompassing qualitative approaches capable of capturing the complexity of relational systems processes, alongside more traditional quantitative methods.

Resilience among asylum seekers living with HIV

BackgroundA small body of evidence demonstrates the challenges faced by migrant communities living with HIV but has yet to consider in-depth the experience of asylum seekers whose residency status is undetermined. The overall aim of our study was to explore the experiences of those who are both living with HIV and seeking asylum. This paper focuses on the stressors precipitated by the HIV diagnosis and by going through the asylum system; as well as participants’ resilience in responding to these stressors and the consequences for their health and wellbeing.MethodsWe conducted an ethnographic study. Fieldwork took place in the UK between 2008–2009 and included: 350 hours of observation at voluntary services providing support to black and minority ethnic groups living with HIV; 29 interviews and four focus group discussions with those who were seeking asylum and living with HIV; and 15 interviews with their health and social care providers. Data were analysed using the constant comparative method.ResultsThere were three main stressors that threatened participants’ resilience. First, migration caused them to leave behind many resources (including social support). Second, stigmatising attitudes led their HIV diagnosis to be a taboo subject furthering their isolation. Third, they found themselves trapped in the asylum system, unable to influence the outcome of their case and reliant on HIV treatment to stay alive. Participants were, however, very resourceful in dealing with these experiences. Resilience processes included: staying busy, drawing on personal faith, and the support received through HIV care providers and voluntary organisations. Even so, their isolated existence meant participants had limited access to social resources, and their treatment in the asylum system had a profound impact on perceived health and wellbeing.ConclusionsAsylum seekers living with HIV in the UK show immense resilience. However, their isolation means they are often unable to deal with their treatment in the asylum system, with negative consequences for their perceived health and wellbeing.

052 Systematic review: the use of research evidence by public health policy-makers

Objective To review: the process of public health policy-making; variations in the extent of research evidence used; other influencing factors; and barriers to and facilitators of the use of research evidence. Design Systematic review of empirical studies reporting data on policy-making in public health. Data Sources Databases searched: MEDLINE, SCOPUS, PsychInfo, CINAHL, The Social Science Citation Index, The Science Citation Index, The Arts and Humanities Citation Index, Applied Social Sciences Index and Abstracts, Database of Reviews of Effects, Cochrane Database of Systematic Reviews, DoPHER, the Campbell Library, and the Cochrane Register of Controlled trials. Other sources: screening of organisational websites, contacting key informants and scrutinising the bibliographies of included studies. Review methods Two reviewers independently assessed studies for inclusion; extracted data and assessed methodological quality using predesigned forms. Disagreements were resolved by consensus or by recourse to a third reviewer. Data were synthesised as a narrative review. Results 1216 articles were retrieved. Following screening 18 studies were included: 13 qualitative studies, four surveys and one literature review. Participants included 1200 policy-makers, 72 researchers, and 174 people involved in both activities. Studies were set in a range of country and policy-making settings. Methodological quality was mixed. The process of policy-making varies widely between settings, and is viewed differently by key players. An extensive range of types of research evidence are used in policy-making. However, it has only an indirect impact and competes with many other influences. Barriers to the use of research evidence are well-described and include: policy-makers’ perceptions of research evidence; the gulf between researchers and policy-makers; the culture in which policy-makers work; competing influences on policy-making; and practical constraints. Ways of overcoming these barriers are less well known, and include: research targeted at the needs of policy-makers; research clearly highlighting key messages; and capacity building. There is almost no evidence on the role of research evidence in addressing health inequalities, a key aim of public health policy. Conclusions Action is required by both policy-makers and researchers to address the barriers identified in this systematic review. There is an urgent need for evidence on the best approaches to incorporating research evidence in public health policy, particularly that considering the complex effects on health inequalities.

Reframing “participation” and “inclusion” in public health policy and practice to address health inequalities: Evidence from a major resident-led neighbourhood improvement initiative

There is a need for greater conceptual clarity in place-based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident-led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident-led partnerships across England are tackling the day-to-day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.

The health impacts of women's low control in their living environment: A theory-based systematic review of observational studies in societies with profound gender discrimination.

Abstract We conducted a systematic review of observational evidence on the health impacts of womens low control/autonomy in the living environment in societies with profound gender discrimination and gender bias. Thirty observational studies of varying methodological quality were included. Overall, the evidence suggests that womens lower control or autonomy (for example lack of freedom of movement outside the home, lack of authority to access healthcare for sick children) was associated with poorer mental and physical health for women and higher morbidity and mortality for their children, after adjusting for their socioeconomic circumstances. Further studies are needed to disentangle and understand the pathways between low control and health outcomes in contexts of profound gender discrimination. This systematic review has highlighted the general low quality of the evidence base on this research question. It identifies the pressing need for high quality, longitudinal studies in the future. HighlightsTheory posits that restricted autonomy of women in societies with profound gender discrimination may lead to poorer health.Lower control over health determinants in their living environment may lead to poorer health outcomes for women and children.This theory‐based systematic review examined the impact of womens low control in the living environment on health outcomes.The evidence suggests that womens low control in their living environment is associated with adverse health outcomes.There are adverse effects on the health of women and their children in societies with profound gender discrimination.Further high quality longitudinal studies are needed to disentangle and understand these pathways in greater depth.

OP28 What is the impact on health and wellbeing of interventions that foster respect and social inclusion in community-resident older adults? A systematic review of empirical studies

Background Diminished respect and social inclusion may negatively impact on older people’s health. Although many interventions promoting respect and social inclusion have been developed, the evidence of their impacts is unclear. This systematic review aimed to identify the effects of such interventions on the health of older people, as part of an empirical investigation of this topic in Liverpool. Methods Eligible studies were identified by searching six bibliographic databases using a pre-piloted strategy, screening reference lists of retrieved items and searching organisational websites (January 1990 to January 2015). The study inclusion criteria were: included community-resident people aged 60+; measured the impact of an intervention to promote respect and social inclusion on physical/mental health; published in English. All study designs were eligible. Titles and abstracts, and full texts were screened for eligibility by one reviewer. A second reviewer independently screened a 10 percent random sample. One reviewer extracted data into standardised forms, and assessed the quality and risk of bias using the Liverpool University Quality Assessment Tool for quantitative studies, and an adapted version of a tool developed by Harden et al, and May and Pope for qualitative studies. Narrative synthesis of study findings was conducted as heterogeneity of interventions, outcomes and designs precluded meta-analysis. Results Of 27,354 records retrieved, 62 studies (31 quantitative, 9 qualitative, 22 mixed methods) met inclusion criteria. A broad range of interventions were identified, focusing on: mentoring; dancing; music/singing; art and culture; information-communication technology; intergenerational programmes. Most studies had high risk of bias, particularly regarding sample representativeness. Impacts were reported on a varied range of health outcomes. For example, music/singing improved mental health related quality of life and anxiety, dancing interventions improved balance and stability, and intergenerational interventions improved depressive symptoms/mood, quality of life, and wellbeing. Qualitative evidence enhanced understanding of health and psychological benefits of the interventions reported by older people, as standard outcome measures (e.g. depression scales) often failed to capture the nuanced effects of interventions. Conclusion Whilst this review indicated that interventions on respect and social inclusion impact positively upon the health of older people, the included studies were heterogeneous and many had considerable risk of bias, which should be addressed in future studies. Many, though not all, of the interventions were delivered as projects to selected groups, raising important questions about feasibility and impact of wider implementation to secure population benefits. Key limitations included searches restricted to date and to English language.