Robert A. Hahn

The Effectiveness of Limiting Alcohol Outlet Density As a Means of Reducing Excessive Alcohol Consumption and Alcohol-Related Harms

The density of alcohol outlets in communities may be regulated to reduce excessive alcohol consumption and related harms. Studies directly assessing the control of outlet density as a means of controlling excessive alcohol consumption and related harms do not exist, but assessments of related phenomena are indicative. To assess the effects of outlet density on alcohol-related harms, primary evidence was used from interrupted time-series studies of outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in license arrangements-all of which affected outlet density. Most of the studies included in this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary evidence was supported by secondary evidence from correlational studies. The regulation of alcohol outlet density may be a useful public health tool for the reduction of excessive alcohol consumption and related harms.

Women's health initiative.

To the Editor: The National Institutes of Health recently launched the Womens Health Initiative (WHI). Although one of us sits on the WHI Advisory Board, we are commenting not in that capacity, bu...

Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis

CONTEXT To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. EVIDENCE ACQUISITION A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. EVIDENCE SYNTHESIS An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). CONCLUSIONS Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level.

The effectiveness of interventions to reduce psychological harm from traumatic events among children and adolescents a systematic review

Children and adolescents in the U.S. and worldwide are commonly exposed to traumatic events, yet practitioners treating these young people to reduce subsequent psychological harm may not be aware of-or use-interventions based on the best available evidence. This systematic review evaluated interventions commonly used to reduce psychological harm among children and adolescents exposed to traumatic events. Guide to Community Preventive Services (Community Guide) criteria were used to assess study design and execution. Meta-analyses were conducted, stratifying by traumatic exposures. Evaluated interventions were conducted in high-income economies, published up to March 2007. Subjects in studies were <or=21 years of age, exposed to individual/mass, intentional/unintentional, or manmade/natural traumatic events. The seven evaluated interventions were individual cognitive-behavioral therapy, group cognitive behavioral therapy, play therapy, art therapy, psychodynamic therapy, and pharmacologic therapy for symptomatic children and adolescents, and psychological debriefing, regardless of symptoms. The main outcome measures were indices of depressive disorders, anxiety and posttraumatic stress disorder, internalizing and externalizing disorders, and suicidal behavior. Strong evidence (according to Community Guide rules) showed that individual and group cognitive-behavioral therapy can decrease psychological harm among symptomatic children and adolescents exposed to trauma. Evidence was insufficient to determine the effectiveness of play therapy, art therapy, pharmacologic therapy, psychodynamic therapy, or psychological debriefing in reducing psychological harm. Personnel treating children and adolescents exposed to traumatic events should use interventions for which evidence of effectiveness is available, such as individual and group cognitive-behavior therapy. Interventions should be adapted for use in diverse populations and settings. Research should be pursued on the effectiveness of interventions for which evidence is currently insufficient.

Profound bilateral blindness and the incidence of breast cancer.

This case-control study addressed the hypothesis that uninterrupted exposure to light is associated with increased rates of breast cancer. We compared the odds of profound binocular blindness among women with a diagnosis of breast cancer with the odds of profound binocular blindness among women with diagnoses of coronary heart disease or stroke. All hospital discharges in the National Hospital Discharge Survey from 1979 through 1987 were analyzed, after exclusion of women with diabetes. Profoundly blind women were half as likely to have breast cancer as women who were not profoundly blind. This effect diminished substantially with increasing age.

Effectiveness of Policies Restricting Hours of Alcohol Sales in Preventing Excessive Alcohol Consumption and Related Harms

Local, state, and national policies that limit the hours that alcoholic beverages may be available for sale might be a means of reducing excessive alcohol consumption and related harms. The methods of the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness of such policies. All of the studies included in this review assessed the effects of increasing hours of sale in on-premises settings (in which alcoholic beverages are consumed where purchased) in high-income nations. None of the studies was conducted in the U.S. The review teams initial assessment of this evidence suggested that changes of less than 2 hours were unlikely to significantly affect excessive alcohol consumption and related harms; to explore this hypothesis, studies assessing the effects of changing hours of sale by less than 2 hours and by 2 or more hours were assessed separately. There was sufficient evidence in ten qualifying studies to conclude that increasing hours of sale by 2 or more hours increases alcohol-related harms. Thus, disallowing extensions of hours of alcohol sales by 2 or more should be expected to prevent alcohol-related harms, while policies decreasing hours of sale by 2 hours or more at on-premises alcohol outlets may be an effective strategy for preventing alcohol-related harms. The evidence from six qualifying studies was insufficient to determine whether increasing hours of sale by less than 2 hours increases excessive alcohol consumption and related harms.

Guide to community preventive serviceThe Effectiveness of Interventions to Reduce Psychological Harm from Traumatic Events Among Children and Adolescents: A Systematic Review

Children and adolescents in the U.S. and worldwide are commonly exposed to traumatic events, yet practitioners treating these young people to reduce subsequent psychological harm may not be aware of-or use-interventions based on the best available evidence. This systematic review evaluated interventions commonly used to reduce psychological harm among children and adolescents exposed to traumatic events. Guide to Community Preventive Services (Community Guide) criteria were used to assess study design and execution. Meta-analyses were conducted, stratifying by traumatic exposures. Evaluated interventions were conducted in high-income economies, published up to March 2007. Subjects in studies were <or=21 years of age, exposed to individual/mass, intentional/unintentional, or manmade/natural traumatic events. The seven evaluated interventions were individual cognitive-behavioral therapy, group cognitive behavioral therapy, play therapy, art therapy, psychodynamic therapy, and pharmacologic therapy for symptomatic children and adolescents, and psychological debriefing, regardless of symptoms. The main outcome measures were indices of depressive disorders, anxiety and posttraumatic stress disorder, internalizing and externalizing disorders, and suicidal behavior. Strong evidence (according to Community Guide rules) showed that individual and group cognitive-behavioral therapy can decrease psychological harm among symptomatic children and adolescents exposed to trauma. Evidence was insufficient to determine the effectiveness of play therapy, art therapy, pharmacologic therapy, psychodynamic therapy, or psychological debriefing in reducing psychological harm. Personnel treating children and adolescents exposed to traumatic events should use interventions for which evidence of effectiveness is available, such as individual and group cognitive-behavior therapy. Interventions should be adapted for use in diverse populations and settings. Research should be pursued on the effectiveness of interventions for which evidence is currently insufficient.

Identifying ancestry: The reliability of ancestral identification in the United States by self, proxy, interviewer, and funeral director.

We examined consistency in the classification of ancestry by self, proxy, interviewer, and funeral director (on a death certificate) in a sample of the U.S. population—the First National Health and Nutrition Examination Survey and Epidemiologic Follow-up. Among study subjects for whom comparable ethnic identity options were available at both interviews, 58% of subjects specified the same identity at two times. Persons who specified four different ethnic backgrounds were 3.4 times as likely to change their identity over time as persons specifying only one background. Self-classification of ancestry at initial interview was consistent with proxy reports at follow-up for 55% of subjects for whom proxy information was available. Comparison of the self-classification of ancestry with the classification of race by interviewers and by funeral directors indicates high consistency for Whites and Blacks and low consistency for American Indians. The “measurement” of ancestry (that is, race or ethnicity) is critical to the understanding and elimination of differences in health status among racial/ethnic populations, but the low reliability of these measures over time and across observers complicates the analysis and interpretation of health statistics by ancestry, particularly for populations other than White or Black.

Complex interventions and their implications for systematic reviews: A pragmatic approach

Complex interventions present unique challenges for systematic reviews. Current debates tend to center around describing complexity, rather than providing guidance on what to do about it. At a series of meetings during 2009-2012, we met to review the challenges and practical steps reviewer could take to incorporate a complexity perspective into systematic reviews. Based on this, we outline a pragmatic approach to dealing with complexity, beginning, as for any review, with clearly defining the research question(s). We argue that reviews of complex interventions can themselves be simple or complex, depending on the question to be answered. In systematic reviews and evaluations of complex interventions, it will be helpful to start by identifying the sources of complexity, then mapping aspects of complexity in the intervention onto the appropriate sources of evidence (such as specific types of quantitative or qualitative study). Although we focus on systematic reviews, the general approach is also applicable to primary research that is aimed at evaluating complex interventions. Although the examples are drawn from health care, the approach may also be applied to other sectors (e.g., social policy or international development). We end by concluding that systematic reviews should follow the principle of Occams razor: explanations should be as complex as they need to be and no more.

Effectiveness of Policies Maintaining or Restricting Days of Alcohol Sales on Excessive Alcohol Consumption and Related Harms

Local, state, and national laws and policies that limit the days of the week on which alcoholic beverages may be sold may be a means of reducing excessive alcohol consumption and related harms. The methods of the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness for preventing excessive alcohol consumption and related harms of laws and policies maintaining or reducing the days when alcoholic beverages may be sold. Outcomes assessed in 14 studies that met qualifying criteria were excessive alcohol consumption and alcohol-related harms, including motor vehicle injuries and deaths, violence-related and other injuries, and health conditions. Qualifying studies assessed the effects of changes in days of sale in both on-premises settings (at which alcoholic beverages are consumed where purchased) and off-premises settings (at which alcoholic beverages may not be consumed where purchased). Eleven studies assessed the effects of adding days of sale, and three studies assessed the effects of imposing a ban on sales on a given weekend day. The evidence from these studies indicated that increasing days of sale leads to increases in excessive alcohol consumption and alcohol-related harms and that reducing the number of days that alcoholic beverages are sold generally decreases alcohol-related harms. Based on these findings, when the expansion of days of sale is being considered, laws and policies maintaining the number of days of the week that alcoholic beverages are sold at on- and off-premises outlets in local, state, and national jurisdictions are effective public health strategies for preventing excessive alcohol consumption and related harms.