Patrick Tobi

Well London Phase-1: results among adults of a cluster-randomised trial of a community engagement approach to improving health behaviours and mental well-being in deprived inner-city neighbourhoods

Background We report the main results, among adults, of a cluster-randomised-trial of Well London, a community-engagement programme promoting healthy eating, physical activity and mental well-being in deprived neighbourhoods. The hypothesis was that benefits would be neighbourhood-wide, and not restricted to intervention participants. The trial was part of a multicomponent process/outcome evaluation which included non-experimental components (self-reported behaviour change amongst participants, case studies and evaluations of individual projects) which suggested health, well-being and social benefits to participants. Methods Twenty matched pairs of neighbourhoods in London were randomised to intervention/control condition. Primary outcomes (five portions fruit/vegetables/day; 5×30 m of moderate intensity physical activity/week, abnormal General Health Questionnaire (GHQ)-12 score and Warwick–Edinburgh Mental Well-being Scale (WEMWBS) score) were measured by postintervention questionnaire survey, among 3986 adults in a random sample of households across neighbourhoods. Results There was no evidence of impact on primary outcomes: healthy eating (relative risk [RR] 1.04, 95% CI 0.93 to 1.17); physical activity (RR:1.01, 95% CI 0.88 to 1.16); abnormal GHQ12 (RR:1.15, 95% CI 0.84 to 1.61); WEMWBS (mean difference [MD]: −1.52, 95% CI −3.93 to 0.88). There was evidence of impact on some secondary outcomes: reducing unhealthy eating-score (MD: −0.14, 95% CI −0.02 to 0.27) and increased perception that people in the neighbourhood pulled together (RR: 1.92, 95% CI 1.12 to 3.29). Conclusions The trial findings do not provide evidence supporting the conclusion of non-experimental components of the evaluation that intervention improved health behaviours, well-being and social outcomes. Low participation rates and population churn likely compromised any impact of the intervention. Imprecise estimation of outcomes and sampling bias may also have influenced findings. There is a need for greater investment in refining such programmes before implementation; new methods to understand, longitudinally different pathways residents take through such interventions and their outcomes, and new theories of change that apply to each pathway.

A multilevel analysis of the association between social networks and support on leisure time physical activity: Evidence from 40 disadvantaged areas in London

There has been extensive conceptual and empirical work on the associations between social relations and health in recent years. However, the specific pathways through which social interactions impact on health have not been fully elucidated. The aim of this paper is to estimate associations between Leisure Time Physical Activity (LTPA) and social networks and support. Using data from a cross-sectional household survey in 40 disadvantaged lower super-output areas in London, we applied a multilevel model to investigate psychosocial and environmental determinants of physical activity in these populations. Our findings present a strong case for the influence of individual-level social networks on the level of LTPA, although the associations between the types of social support and LTPA were insignificant. We also found that crime rate was an important area-level correlates of LTPA.

Why do health systems matter? Exploring links between health systems and HIV response: a case study from Russia

INTRODUCTION Studies on the relevance of stronger health systems to the success of vertical programmes has focused mainly on developing countries with fragile infrastructures and limited human resources. Research in middle-income, and particularly post-Soviet, settings has been scarce. This article examines the relationships between health system characteristics and the HIV response in Russia, the country which towards the end of the Soviet period had the worlds highest ratios of doctors and hospital beds to population and yet struggled to address the growing threat of HIV/AIDS. METHODS The study is based on semi-structured qualitative interviews with policy-makers and senior health care managers in two Russian regions, and a review of published and unpublished sources on health systems and HIV in Russia. FINDINGS We identified a number of factors associated with the systems failure to address the epidemic. We argue that these factors are not unique to HIV/AIDS. The features of the wider health system within which the HIV response was set up influenced the structure and capacities of the programme, particularly its regulatory and clinical orientation; the discrepancy between formal commitments and implementation; the focus on screening services; and problems with scaling up interventions targeting high-risk groups. DISCUSSION The system-programme interplay is as important in middle-income countries as in poorer settings. An advanced health care infrastructure cannot protect health systems from potential failures in the delivery of vertical programmes. The HIV response cannot be effective, efficient and responsive to the needs of the population if the broader health system does not adhere to the same principles. Strengthening HIV responses in post-Soviet societies will require improvements in their wider health systems, namely advocacy of prevention for high-risk populations, reallocation of resources from curative towards preventive services, building decision-making capacities at the local level, and developing better working environments for health care staff.

The Well London program - a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results

BackgroundThe Well London program used community engagement, complemented by changes to the physical and social neighborhood environment, to improve physical activity levels, healthy eating, and mental wellbeing in the most deprived communities in London. The effectiveness of Well London is being evaluated in a pair-matched cluster randomized trial (CRT). The baseline survey data are reported here.MethodsThe CRT involved 20 matched pairs of intervention and control communities (defined as UK census lower super output areas (LSOAs); ranked in the 11% most deprived LSOAs in London by the English Indices of Multiple Deprivation) across 20 London boroughs. The primary trial outcomes, sociodemographic information, and environmental neighbourhood characteristics were assessed in three quantitative components within the Well London CRT at baseline: a cross-sectional, interviewer-administered adult household survey; a self-completed, school-based adolescent questionnaire; a fieldworker completed neighborhood environmental audit. Baseline data collection occurred in 2008. Physical activity, healthy eating, and mental wellbeing were assessed using standardized, validated questionnaire tools. Multiple imputation was used to account for missing data in the outcomes and other variables in the adult and adolescent surveys.ResultsThere were 4,107 adults and 1,214 adolescent respondents in the baseline surveys. The intervention and control areas were broadly comparable with respect to the primary outcomes and key sociodemographic characteristics. The environmental characteristics of the intervention and control neighborhoods were broadly similar. There was greater between-cluster variation in the primary outcomes in the adult population compared to the adolescent population. Levels of healthy eating, smoking, and self-reported anxiety/depression were similar in the Well London adult population and the national Health Survey for England. Levels of physical activity were higher in the Well London adult population but this is likely to be due to the different measurement tools used in the two surveys.ConclusionsRandomization of social interventions such as Well London is acceptable and feasible and in this study the intervention and control arms are well-balanced with respect to the primary outcomes and key sociodemographic characteristics. The matched design has improved the statistical efficiency of the study amongst adults but less so amongst adolescents. Follow-up data collection will be completed 2012.Trial registrationCurrent Controlled Trials ISRCTN68175121

Antiretroviral treatment and the health workforce in South Africa: how have ART workers been affected by scaling up?

Objective  To investigate the effect of scaling up antiretroviral treatment (ART) on the working environment and motivation of health workers in South Africa; and to suggest strategies to minimize negative effects and maximise positive effects.

Who stays, who drops out? Biosocial predictors of longer-term adherence in participants attending an exercise referral scheme in the UK

BackgroundExercise referral schemes are one of the most popular forms of physical activity intervention in primary care in the UK and present an opportunity to better understand the factors related to exercise adherence. But standard schemes tend to be delivered over a short period and so provide information about the factors associated with short-term adherence. This retrospective register-based study of a longer-duration scheme allowed investigation of longer-term adherence.MethodsSocial, physiological and anthropometric data were extracted from records of a cohort of ERS participants who had enrolled between 01 January and 31 December 2007 (n = 701). Characteristics of adherers and non-adherers were compared and potential predictors of longer-term adherence examined using binomial logistic regression.ResultsSignificant adjusted odds ratios predicting longer-term adherence were found for age and medical condition. For every 10 year increase in age, the odds of people continuing exercise increased by 21.8% (OR = 1.02; CI = 1.00 to 1.04; p = 0.03). Participants referred with orthopaedic (OR = 0.25; CI = 0.07-0.94; p = 0.04), cardiovascular (OR = 0.18; CI = 0.05-0.70; p = 0.01) and other (OR = 0.20; CI = 0.04-0.93; p = 0.04) problems had significantly lower odds of adhering than those with metabolic conditions.ConclusionImproved understanding of the factors that influence adherence to exercise referral schemes will enable providers develop better referral guidance and tailor schemes to better meet participants’ needs. Longer-term schemes offer the opportunity to understand participants’ likelihood of maintaining adherence to exercise.

Measures of exposure to the Well London Phase-1 intervention and their association with health well-being and social outcomes

In this paper, we describe the measures of intervention exposure used in the cluster randomised trial of the Well London programme, a public health intervention using community engagement and community-based projects to increase physical activity, healthy eating and mental health and well-being in 20 of the most deprived neighbourhoods in London.10 No earmarked resources to support the development of these measures and associated data collection were provided to either the research team or to those delivering the interventions on the ground. Instead, these were derived from contractually specified performance management information reported quarterly by partners and by inclusion of questions seeking information about participation in the follow-up questionnaires used to measure the main trial outcomes. The exposure measures are consequently considerably less sophisticated than those used in the US studies, where earmarked funding was available.

Types of social capital and mental disorder in deprived urban areas: a multilevel study of 40 disadvantaged London neighbourhoods.

Objectives To examine the extent to which individual and ecological-level cognitive and structural social capital are associated with common mental disorder (CMD), the role played by physical characteristics of the neighbourhood in moderating this association, and the longitudinal change of the association between ecological level cognitive and structural social capital and CMD. Design Cross-sectional and longitudinal study of 40 disadvantaged London neighbourhoods. We used a contextual measure of the physical characteristics of each neighbourhood to examine how the neighbourhood moderates the association between types of social capital and mental disorder. We analysed the association between ecological-level measures of social capital and CMD longitudinally. Participants 4,214 adults aged 16-97 (44.4% men) were randomly selected from 40 disadvantaged London neighbourhoods. Main Outcome Measures General Health Questionnaire (GHQ-12). Results Structural rather than cognitive social capital was significantly associated with CMD after controlling for socio-demographic variables. However, the two measures of structural social capital used, social networks and civic participation, were negatively and positively associated with CMD respectively. ‘Social networks’ was negatively associated with CMD at both the individual and ecological levels. This result was maintained when contextual aspects of the physical environment (neighbourhood incivilities) were introduced into the model, suggesting that ‘social networks’ was independent from characteristics of the physical environment. When ecological-level longitudinal analysis was conducted, ‘social networks’ was not statistically significant after controlling for individual-level social capital at follow up. Conclusions If we conceptually distinguish between cognitive and structural components as the quality and quantity of social capital respectively, the conclusion of this study is that the quantity rather than quality of social capital is important in relation to CMD at both the individual and ecological levels in disadvantaged urban areas. Thus, policy should support interventions that create and sustain social networks. One of these is explored in this article. Trial Registration Controlled-Trials.com ISRCTN68175121 http://www.controlled-trials.com/ISRCTN68175121

The impact of ART scale upon health workers: evidence from two South African districts.

Abstract This study explores the effects of antiretroviral treatment (ART) programmes on health-care human resources in South Africa. The study included two parts, a questionnaire-based survey of 269 health workers published earlier and a qualitative study of 21 purposively selected health practitioners involved in ART scale up. Contrary to what has been presented in literature, our survey showed that health workers in ART programmes experienced higher levels of morale, lower stress, lower sickness absenteeism and higher levels of job satisfaction. This paper uses qualitative data to provide insights into the working environment of ART workers and examines some possible explanations for our survey findings. The key factors that contribute to the different perception of working environment by ART workers identified in this study include bringing hope to patients, delaying deaths, acquiring training and the ability to better manage and monitor the disease.

Physical Activity in Deprived Communities in London: Examining Individual and Neighbourhood-Level Factors

Introduction The objectives of this study were to examine relationships between neighbourhood-level and individual-level characteristics and physical activity in deprived London neighbourhoods. Methods In 40 of the most deprived neighbourhoods in London (ranked in top 11% in London by Index of Multiple Deprivation) a cross-sectional survey (n = 4107 adults aged > = 16 years), neighbourhood audit tool, GIS measures and routine data measured neighbourhood and individual-level characteristics. The binary outcome was meeting the minimum recommended (CMO, UK) 5×30 mins moderate physical activity per week. Multilevel modelling was used to examine associations between physical activity and individual and neighbourhood-level characteristics. Results Respondents living more than 300 m away from accessible greenspace had lower odds of achieving recommended physical activity levels than those who lived within 300 m; from 301–600 m (OR = 0.7; 95% CI 0.5–0.9) and from 601–900 m (OR = 0.6; 95% CI 0.4–0.8). There was substantial residual between-neighbourhood variance in physical activity (median odds ratio = 1.7). Other objectively measured neighbourhood-level characteristics were not associated with physical activity levels. Conclusions Distance to nearest greenspace is associated with meeting recommended physical activity levels in deprived London neighbourhoods. Despite residual variance in physical activity levels between neighbourhoods, we found little evidence for the influence of other measured neighbourhood-level characteristics.