Melissa Palmer

Social determinants of tuberculosis in Europe: a prospective ecological study

Tuberculosis (TB) is considered to be a disease of poverty, since its incidence is exacerbated by socioeconomic factors, inconsistent or partial treatment practices, and immigration from endemic countries. A prospective country level study, using a comprehensive dataset of TB incidence and prevalence taken from countries within the World Health Organization (WHO) European region, was conducted. We employed quintile regression to investigate the prospective association between baseline (measured in 2000) and a nation’s wealth, level of egalitarianism, migration rate, health-related lifestyle and social capital with TB incidence and prevalence over a 10-yr period (2000–2009). We found that ∼50% of TB variation is accounted for by a nations wealth and level of egalitarianism. We observed a negative prospective association between logged gross domestic product and TB rates, and a positive prospective association between income inequality and TB. National income levels per capita and income inequality are important predictors for TB incidence and prevalence in the WHO European region. They account for 50% of country-level variation, indicating the importance of a combined absolute and relative socioeconomic disadvantage in the development of TB. These findings also provide a tool for forecasting potential fluctuations in the level of TB epidemics in the WHO European region, with respect to socioeconomic changes.

Prevalence of infertility and help seeking among 15 000 women and men.

STUDY QUESTION What is the prevalence of infertility and of help seeking among women and men in Britain? SUMMARY ANSWER One in eight women and one in ten men aged 16–74 years had experienced infertility, defined by unsuccessfully attempting pregnancy for a year or longer, and little more than half of these people sought medical or professional help. WHAT IS KNOWN ALREADY Estimates of infertility and help seeking in Britain vary widely and are not easily comparable because of different definitions and study populations. STUDY DESIGN, SIZE, DURATION A cross-sectional population survey was conducted between 2010 and 2012 with a sample of 15 162 women and men aged 16–74 years. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants completed the Natsal-3 questionnaire, using computer-assisted personal interviewing (CAPI) and computer-assisted self-interview (CASI). MAIN RESULTS AND THE ROLE OF CHANCE The reported prevalence of infertility was 12.5% (CI 95% 11.7–13.3) among women and 10.1% (CI 95% 9.2–11.1) among men. Increased prevalence was associated with later cohabitation with a partner, higher socio-economic status and, for those who had a child, becoming parents at older ages. The reported prevalence of help seeking was 57.3% (CI 95% 53.6–61.0) among women and 53.2% (CI 95% 48.1–58.1) among men. Help seekers were more likely to be better educated and in higher status occupations and, among those who had a child, to have become parents later in life. LIMITATIONS, REASONS FOR CAUTION These data are cross-sectional so it is not possible to establish temporality or infer causality. Self-reported data may be subject to recall bias. WIDER IMPLICATIONS OF THE FINDINGS The study provides estimates of infertility and help seeking in Britain and the results indicate that the prevalence of infertility is higher among those delaying parenthood. Those with higher educational qualifications and occupational status are more likely to consult with medical professionals for fertility problems than others and these inequalities in help seeking should be considered by clinical practice and public health. STUDY FUNDING/COMPETING INTEREST(S) Funding was provided by grants from the Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health. AMJ is a Governor of the Wellcome Trust. Other authors have no competing interests.

Associations between source of information about sex and sexual health outcomes in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Objectives To examine variation in source of information about sexual matters by sociodemographic factors, and associations with sexual behaviours and outcomes. Design Cross-sectional probability sample survey. Setting British general population. Participants 3408 men and women, aged 17–24 years, interviewed from 2010–2012 for third National Survey of Sexual Attitudes and Lifestyles. Main outcome measures Main source of information (school, a parent, other); age and circumstances of first heterosexual intercourse; unsafe sex and distress about sex in past year; experience of sexually transmitted infection (STI) diagnoses, non-volitional sex or abortion (women only) ever. Results Citing school was associated with younger age, higher educational level and having lived with both parents. Citing a parent was associated, in women, with lower educational level and having lived with one parent. Relative to other sources, citing school was associated with older age at first sex (adjusted HR 0.73 (95% CI 0.65 to 0.83) men, 0.73 (0.65 to 0.82) women), lower likelihood of unsafe sex (adjusted OR 0.58 (0.44 to 0.77) men, 0.69 (0.52 to 0.91) women) and previous STI diagnosis (0.55 (0.33 to 0.91) men, 0.58 (0.43 to 0.80) women) and, in women, with lower likelihood of lack of sexual competence at first sex; and experience of non-volitional sex, abortion and distress about sex. Citing a parent was associated with lower likelihood of unsafe sex (0.53 (0.28 to 1.00) men; 0.69 (0.48 to 0.99) women) and, in women, previous STI diagnosis. Conclusions Gaining information mainly from school was associated with lower reporting of a range of negative sexual health outcomes, particularly among women. Gaining information mainly from a parent was associated with some of these, but fewer cited parents as a primary source. The findings emphasise the benefit of school and parents providing information about sexual matters and argue for a stronger focus on the needs of men.

Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000–12: an observational study

Summary Background In 2000, a 10-year Teenage Pregnancy Strategy was launched in England to reduce conceptions in women younger than 18 years and social exclusion in young parents. We used routinely collected data and data from Britains National Surveys of Sexual Attitudes and Lifestyles (Natsal) to examine progress towards these goals. Methods In this observational study, we used random-effects meta-regression to analyse the change in conception rates from 1994–98 to 2009–13 by top-tier local authorities in England, in relation to Teenage Pregnancy Strategy-related expenditure per head, socioeconomic deprivation, and region. Data from similar probability sample surveys: Natsal-1 (1990–91), Natsal-2 (1999–2001), and Natsal-3 (2010–12) were used to assess the prevalence of risk factors and their association with conception in women younger than 18 years in women aged 18–24 years; and the prevalence of participation in education, work, and training in young mothers. Findings Conception rates in women younger than 18 years declined steadily from their peak in 1996–98 and more rapidly from 2007 onwards. More deprived areas and those receiving greater Teenage Pregnancy Strategy-related investment had higher rates of conception in 1994–98 and had greater declines to 2009–13. Regression analyses assessing the association between Teenage Pregnancy Strategy funding and decline in conception rates in women younger than 18 years showed an estimated reduction in the conception rate of 11·4 conceptions (95% CI 9·6–13·2; p<0·0001) per 1000 women aged 15–17 years for every £100 Teenage Pregnancy Strategy spend per head and a reduction of 8·2 conceptions (5·8–10·5; p<0·0001) after adjustment for socioeconomic deprivation and region. The association between conception in women younger than 18 years and lower socioeconomic status weakened slightly between Natsal-2 and Natsal-3. The prevalence of participation in education, work, or training among young women with a child conceived before age 18 years was low, but the odds of them doing so doubled between Natsal-2 and Natsal-3 (odds ratio 1·99, 95% CI 0·99–4·00). Interpretation A sustained, multifaceted policy intervention involving health and education agencies, alongside other social and educational changes, has probably contributed to a substantial and accelerating decline in conceptions in women younger than 18 years in England since the late 1990s. Funding Medical Research Council, Wellcome Trust, Economic and Social Research Council, and Department of Health.

Internet-accessed sexually transmitted infection (e-STI) testing and results service: A randomised, single-blind, controlled trial.

Background Internet-accessed sexually transmitted infection testing (e-STI testing) is increasingly available as an alternative to testing in clinics. Typically this testing modality enables users to order a test kit from a virtual service (via a website or app), collect their own samples, return test samples to a laboratory, and be notified of their results by short message service (SMS) or telephone. e-STI testing is assumed to increase access to testing in comparison with face-to-face services, but the evidence is unclear. We conducted a randomised controlled trial to assess the effectiveness of an e-STI testing and results service (chlamydia, gonorrhoea, HIV, and syphilis) on STI testing uptake and STI cases diagnosed. Methods and findings The study took place in the London boroughs of Lambeth and Southwark. Between 24 November 2014 and 31 August 2015, we recruited 2,072 participants, aged 16–30 years, who were resident in these boroughs, had at least 1 sexual partner in the last 12 months, stated willingness to take an STI test, and had access to the internet. Those unable to provide consent and unable to read English were excluded. Participants were randomly allocated to receive 1 text message with the web link of an e-STI testing and results service (intervention group) or to receive 1 text message with the web link of a bespoke website listing the locations, contact details, and websites of 7 local sexual health clinics (control group). Participants were free to use any other services or interventions during the study period. The primary outcomes were self-reported STI testing at 6 weeks, verified by patient record checks, and self-reported STI diagnosis at 6 weeks, verified by patient record checks. Secondary outcomes were the proportion of participants prescribed treatment for an STI, time from randomisation to completion of an STI test, and time from randomisation to treatment of an STI. Participants were sent a £10 cash incentive on submission of self-reported data. We completed all follow-up, including patient record checks, by 17 June 2016. Uptake of STI testing was increased in the intervention group at 6 weeks (50.0% versus 26.6%, relative risk [RR] 1.87, 95% CI 1.63 to 2.15, P < 0.001). The proportion of participants diagnosed was 2.8% in the intervention group versus 1.4% in the control group (RR 2.10, 95% CI 0.94 to 4.70, P = 0.079). No evidence of heterogeneity was observed for any of the pre-specified subgroup analyses. The proportion of participants treated was 1.1% in the intervention group versus 0.7% in the control group (RR 1.72, 95% CI 0.71 to 4.16, P = 0.231). Time to test, was shorter in the intervention group compared to the control group (28.8 days versus 36.5 days, P < 0.001, test for difference in restricted mean survival time [RMST]), but no differences were observed for time to treatment (83.2 days versus 83.5 days, P = 0.51, test for difference in RMST). We were unable to recruit the planned 3,000 participants and therefore lacked power for the analyses of STI diagnoses and STI cases treated. Conclusions The e-STI testing service increased uptake of STI testing for all groups including high-risk groups. The intervention required people to attend clinic for treatment and did not reduce time to treatment. Service innovations to improve treatment rates for those diagnosed online are required and could include e-treatment and postal treatment services. e-STI testing services require long-term monitoring and evaluation. Trial registration ISRCTN Registry ISRCTN13354298.

Is “Sexual Competence” at First Heterosexual Intercourse Associated With Subsequent Sexual Health Status?

The timing of first sexual intercourse is often defined in terms of chronological age, with particular focus on “early” first sex. Arguments can be made for a more nuanced concept of readiness and appropriateness of timing of first intercourse. Using data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), conducted in 2010–2012, this study examined whether a context-based measure of first intercourse—termed sexual competence—was associated with subsequent sexual health in a population-based sample of 17-to 24-year-olds residing in Britain (n = 2,784). Participants were classified as “sexually competent” at first intercourse if they reported the following four criteria: contraceptive protection, autonomy of decision (not due to external influences), that both partners were “equally willing,” and that it happened at the “right time.” A lack of sexual competence at first intercourse was independently associated with testing positive for human papillomavirus (HPV) at interview; low sexual function in the past year; and among women only, reported sexually transmitted infection (STI) diagnosis ever; unplanned pregnancy in the past year; and having ever experienced nonvolitional sex. These findings provide empirical support for defining the nature of first intercourse with reference to contextual aspects of the experience, as opposed to a sole focus on chronological age at occurrence.

The effectiveness of smoking cessation, physical activity/diet and alcohol reduction interventions delivered by mobile phones for the prevention of non-communicable diseases: A systematic review of randomised controlled trials

Background We conducted a systematic review to assess the effectiveness of smoking cessation, physical activity (PA), diet, and alcohol reduction interventions delivered by mobile technology to prevent non-communicable diseases (NCDs). Methods We searched for randomised controlled trials (RCTs) of mobile-based NCD prevention interventions using MEDLINE, EMBASE, Global Health, CINAHL (Jan 1990–Jan 2016). Two authors extracted data. Findings 71 trials were included: smoking cessation (n = 18); PA (n = 15), diet (n = 3), PA and diet (n = 25); PA, diet, and smoking cessation (n = 2); and harmful alcohol consumption (n = 8). 4 trials had low risk of bias. The effect of SMS-based smoking cessation support on biochemically verified continuous abstinence was pooled relative risk [RR] 2.19 [95% CI 1.80–2.68], I2 = 0%) and on verified 7 day point prevalence of smoking cessation was pooled RR 1.51 [95% CI 1.06–2.15], I2 = 0%, with no reported adverse events. There was no difference in peak oxygen intake at 3 months in a trial of an SMS-based PA intervention. The effect of SMS-based diet and PA interventions on: incidence of diabetes was pooled RR 0.67 [95% CI 0.49, 0.90], I2 = 0.0%; end-point weight was pooled MD -0.99Kg [95% CI -3.63, 1.64] I2 = 29.4%; % change in weight was pooled MD -3.1 [95%CI -4.86- -1.3] I2 0.3%; and on triglyceride levels was pooled MD -0.19 mmol/L [95% CI -0.29, -0.08], I2 = 0.0%. The results of other pooled analyses of the effect of SMS-based diet and PA interventions were heterogenous (I2 59–90%). The effects of alcohol reduction interventions were inconclusive. Conclusions Smoking cessation support delivered by SMS increases quitting rates. Trials of PA interventions reporting outcomes ≥3 months showed no benefits. There were at best modest benefits of diet and PA interventions. The effects of the most promising SMS-based smoking, diet and PA interventions on morbidity and mortality in high-risk groups should be established in adequately powered RCTs.

Trends in the use of emergency contraception in Britain: evidence from the second and third National Surveys of Sexual Attitudes and Lifestyles

To examine the changes in the prevalence of, and the factors associated with, the use of emergency contraception (EC) in Britain between 2000 and 2010, spanning the period of deregulation and increase in pharmacy supply.

Where do women and men in Britain obtain contraception? Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Introduction To estimate the prevalence of use of different sources of contraceptive supplies in Britain and its variation by key demographic and behavioural characteristics. Methods Cross-sectional probability sample survey of women and men aged 16–74 years, resident in Britain, interviewed between 2010 and 2012. Analyses reported here were of 4571 women and 3142 men aged 16–44 years who reported having vaginal sex in the past year. Those relying exclusively on sterilisation (including hysterectomy) were excluded. Sources of contraceptive supplies were categorised as: general practice, community clinic, retail and other. Prevalence of use of these sources was estimated, and associated factors examined. Results Some 87.0% of women and 73.8% of men accessed at least one source of contraceptive supplies in the previous year. Most women (59.1%) used general practice and most men (54.6%) used retail outlets. Community clinics were less commonly used, by 23.0% of women and 21.3% of men, but these users were younger and at greater sexual health risk. These associations were also observed among the 27.3% of women and 30.6% of men who used more than one source category (general practice, community clinic or retail) for contraceptive supplies. Conclusions People in Britain use a variety of sources to obtain contraceptive supplies and some sources are more commonly used by those more vulnerable to poorer sexual health. Our findings suggest that national policy changes to increase access to contraceptive methods have had an effect on the diversity of services used.

Heterosexual Practices Among Young People in Britain: Evidence From Three National Surveys of Sexual Attitudes and Lifestyles

Purpose To describe time trends and current patterns in sexual practices with opposite-sex partners among men and women aged 16–24 years in Britain. Methods Complex survey analyses of cross-sectional probability survey data from three British National Surveys of Sexual Attitudes and Lifestyles (Natsal), conducted approximately decennially 1990–2012, involving interviews with 45,199 people in total. Results Birth cohort analysis showed a decline in the median age at first sexual experience and first intercourse since the midtwentieth century and a narrowing of the interval between these events. Comparison of data from Natsals 1, 2, and 3 showed increases in the prevalence of ever experience of oral and anal sex among 16- to 24-year-olds, which were more marked among older respondents in this age group between Natsals 1 and 2, and among younger respondents between Natsals 2 and 3. Among the sexually active, vaginal and oral sex remained the most common combination of practices reported in the past year. The proportion reporting a past-year repertoire of vaginal, oral, and anal sex rose from approximately one in 10 in 1990–1991 to approximately one in four men and one in five women in 2010–2012. In the latest survey, heterosexual experience of practices was positively associated with bisexual attraction among women. Conclusions Recent decades have seen an earlier age at initiation of partnered sexual experiences and increased diversity in heterosexual practices among young people. Keeping pace with trends in sexual practices is necessary to safeguard young peoples health and to support them in increasing their sexual well-being.