... based studies and the evaluation of multilevel influences on health outcomes Graham Moon, SV S... more ... based studies and the evaluation of multilevel influences on health outcomes Graham Moon, SV Subramanian, Kelvyn Jones, Craig ... deprivation and disability, education, skills and training deprivation, barriers to housing and services, living environment deprivation and crime). ...
Background Community treatment orders are widely used in England. It is unclear whether their use... more Background Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes. Objectives To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs. Design Secondary analysis using multilevel statistical modelling. Setting England, including 61 NHS mental health provider trusts. Participants A total of 69,832 patients eligible to be subject to a community treatment order. Main outcome measures Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality. Data sources The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England. Results There was signifi...
Supervised community treatment (SCT) for people with serious mental disorders has become accepted... more Supervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data. Four years of data from the Mental Health Services Dataset (MHSDS) will be an...
SummaryConventional approaches to evidence that prioritise randomised controlled trials appear in... more SummaryConventional approaches to evidence that prioritise randomised controlled trials appear increasingly inadequate for the evaluation of complex mental health interventions. By focusing on causal mechanisms and understanding the complex interactions between interventions, patients and contexts, realist approaches offer a productive alternative. Although the approaches might be combined, substantial barriers remain.Declaration of interestAll authors had financial support from the National Institute for Health Research Health Services and Delivery Research Programme while completing this work. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, the Medical Research Council, Central Commissioning Facility, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, the Health Services and Delivery Research Programme or the Dep...
An increasing number of countries across the world are planning for the eradication of the tobacc... more An increasing number of countries across the world are planning for the eradication of the tobacco epidemic. The actions necessary to realise this ambition have been termed the tobacco endgame. The focus of this paper is on the intersection between the tobacco endgame with place, a neglected theme in recent academic and policy debates. We begin with an overview of the key themes in the literature on endgame strategies before detailing the international landscape of engame initiatives, paying particular attention to the opportunities and challenges of endgame strategies in low and middle income countries. Finally, we critically assess the current endgame debates and suggest a novel agenda for integrating geographical perspectives into research on the endgame that provides enhanced understanding of the challenges associated with this important global health vision.
ObjectivesThis study aims to address, for the first time, the challenges of constructing small ar... more ObjectivesThis study aims to address, for the first time, the challenges of constructing small area estimates of health status using linked national surveys. The study also seeks to assess the concordance of these small area estimates with data from national censuses.SettingPopulation level health status in England, Scotland and Wales.ParticipantsA linked integrated dataset of 23 374 survey respondents (16+ years) from the 2011 waves of the Health Survey for England (n=8603), the Scottish Health Survey (n=7537) and the Welsh Health Survey (n=7234).Primary and secondary outcome measuresPopulation prevalence of poorer self-rated health and limiting long-term illness. A multilevel small area estimation modelling approach was used to estimate prevalence of these outcomes for middle super output areas in England and Wales and intermediate zones in Scotland. The estimates were then compared with matched measures from the contemporaneous 2011 UK Census.ResultsThere was a strong positive as...
A review of family planning services provided by the Portsmouth and South-East Hampshire Health A... more A review of family planning services provided by the Portsmouth and South-East Hampshire Health Authority in 1988 concluded that more needed to be known about why people used the services and who attended which clinic. In order to address this need, therefore, a survey was conducted on November 8, 1992 among 7 of the most heavily used health authority family planning clinics (FPC) and 7 general practitioner (GP) practices which offer contraceptive services. The GP practices were located close to FPCs. 3 additional GPs were added, of which 2 were not in the health authority area, and 1 was a branch. The survey instrument, which was developed by a select steering group is presented in its entirety. A 96% response rate was achieved. Results showed a median age of 24 years among clinic attendees and an age range of 16-47 years. FPCs tended to have younger clients. There were no differences between GPs and FPCs in the number of miscarriages experienced. FPCs had a large proportion of single (40%), never-married women, while GPs had primarily married or cohabiting women patients. 94% of the GP group reported that the GP practice was their usual location for contraceptive services, while 83% in the FPC group reported the FPC as their usual location. GP use may reflect habit and clinics may attract a more mobile population or referrals. The question pertaining to the usual source of FP advice and information elicited ambiguous responses. Of the data tabulated by age, it appears that 14-16 year old were more likely to choose another FPC, whereas women in other age groups were likely to seek advice from a GP. The reasons for attending a FPC were to be able to consult a woman doctor and to obtain contraceptive supplies. Personal attention from one's own doctor was the reason given for attendance at GP groups. Both facilities reported that oral contraceptives were the most common method used. FPC tended to prescribe alternatives, particularly to young acceptors who were more likely to use oral contraceptives with a barrier method. Contraceptive knowledge is obtained wherever women normally go for advice. Both types of facilities have a continuing and complementary role.
To identify the impact of a smoking cessation programme on area-based social and ethnic inequalit... more To identify the impact of a smoking cessation programme on area-based social and ethnic inequalities in smoking rates through social and ethnic differences in enrolment and quitting. Analysis of records of 11 325 patients who enrolled in an innovative smoking cessation programme in Christchurch, New Zealand between 2001 and 2006. We compare enrolment, follow-up, quitting and impact on population smoking rates in the most and least deprived neighbourhoods and the neighbourhoods with the lowest and highest proportions of Māori. Enrolment as a proportion of the population was higher from the most deprived areas but as a proportion of neighbourhood smokers, it was lower. Enrolees from the least deprived quintile were 40% more likely to quit than those from the most deprived quintile. Smoking rates were 2.84 (2.75 to 2.93) times higher in the most deprived neighbourhoods. If the programme had not been available we estimate that this differential would have reduced to 2.81 (2.72 to 2.90). In neighbourhoods with the highest proportion of Māori, smoking rates were 2.33 (2.26 to 2.41) times higher and we estimate that without the programme smoking rates would be 2.30 (2.23 to 2.37) times higher. Although enrolees were drawn from a wide variety of backgrounds, those most likely to quit tended to reside in affluent areas or areas with a low proportion of Māori. There was no evidence that this smoking cessation programme increased or decreased inequalities within the Christchurch population. For smoking cessation programmes to have an impact on health inequalities more effort is required in targeting hard-to-reach groups and in encouraging them to quit.
General practice is a recommended setting for the delivery of smoking cessation programs. Little ... more General practice is a recommended setting for the delivery of smoking cessation programs. Little is known about the types of practice that achieve higher cessation rates. To address this gap in knowledge, we assessed the impact of general practice characteristics on the outcomes of a large scale smoking cessation intervention delivered in general practice settings. A cross-sectional study was undertaken of 7,778 participants enrolled on a structured cessation program comprising repeated brief interventions in one-to-one sessions and nicotine replacement therapy in Christchurch New Zealand, 2001-2007. We employed a logistic multilevel analysis of respondents nested in general practices with cessation at 6 months as the outcome measure. After taking into account relevant individual-level predictors (age, sex, smoking intensity) and area-level surrogates for individual predictors (socioeconomic status and access to tobacco retail outlets), there remained significant variation in quit rates between practices. This variation reduced when practice characteristics were included. Practices with a majority of male doctors and practices with fewer male patients were associated with better quit rates. Practices with large numbers of doctors were less effective in achieving cessation with heavy smokers. The effectiveness of smoking cessation programs can be influenced significantly by practice characteristics. To increase quit rates, more attention should be paid to the institutional setting of smoking cessation programs. Assessments of the effectiveness of cessation programs should give appropriate recognition to the fact that some practices may find higher quit rates more difficult to achieve.
... based studies and the evaluation of multilevel influences on health outcomes Graham Moon, SV S... more ... based studies and the evaluation of multilevel influences on health outcomes Graham Moon, SV Subramanian, Kelvyn Jones, Craig ... deprivation and disability, education, skills and training deprivation, barriers to housing and services, living environment deprivation and crime). ...
Background Community treatment orders are widely used in England. It is unclear whether their use... more Background Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes. Objectives To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs. Design Secondary analysis using multilevel statistical modelling. Setting England, including 61 NHS mental health provider trusts. Participants A total of 69,832 patients eligible to be subject to a community treatment order. Main outcome measures Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality. Data sources The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England. Results There was signifi...
Supervised community treatment (SCT) for people with serious mental disorders has become accepted... more Supervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data. Four years of data from the Mental Health Services Dataset (MHSDS) will be an...
SummaryConventional approaches to evidence that prioritise randomised controlled trials appear in... more SummaryConventional approaches to evidence that prioritise randomised controlled trials appear increasingly inadequate for the evaluation of complex mental health interventions. By focusing on causal mechanisms and understanding the complex interactions between interventions, patients and contexts, realist approaches offer a productive alternative. Although the approaches might be combined, substantial barriers remain.Declaration of interestAll authors had financial support from the National Institute for Health Research Health Services and Delivery Research Programme while completing this work. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, the Medical Research Council, Central Commissioning Facility, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, the Health Services and Delivery Research Programme or the Dep...
An increasing number of countries across the world are planning for the eradication of the tobacc... more An increasing number of countries across the world are planning for the eradication of the tobacco epidemic. The actions necessary to realise this ambition have been termed the tobacco endgame. The focus of this paper is on the intersection between the tobacco endgame with place, a neglected theme in recent academic and policy debates. We begin with an overview of the key themes in the literature on endgame strategies before detailing the international landscape of engame initiatives, paying particular attention to the opportunities and challenges of endgame strategies in low and middle income countries. Finally, we critically assess the current endgame debates and suggest a novel agenda for integrating geographical perspectives into research on the endgame that provides enhanced understanding of the challenges associated with this important global health vision.
ObjectivesThis study aims to address, for the first time, the challenges of constructing small ar... more ObjectivesThis study aims to address, for the first time, the challenges of constructing small area estimates of health status using linked national surveys. The study also seeks to assess the concordance of these small area estimates with data from national censuses.SettingPopulation level health status in England, Scotland and Wales.ParticipantsA linked integrated dataset of 23 374 survey respondents (16+ years) from the 2011 waves of the Health Survey for England (n=8603), the Scottish Health Survey (n=7537) and the Welsh Health Survey (n=7234).Primary and secondary outcome measuresPopulation prevalence of poorer self-rated health and limiting long-term illness. A multilevel small area estimation modelling approach was used to estimate prevalence of these outcomes for middle super output areas in England and Wales and intermediate zones in Scotland. The estimates were then compared with matched measures from the contemporaneous 2011 UK Census.ResultsThere was a strong positive as...
A review of family planning services provided by the Portsmouth and South-East Hampshire Health A... more A review of family planning services provided by the Portsmouth and South-East Hampshire Health Authority in 1988 concluded that more needed to be known about why people used the services and who attended which clinic. In order to address this need, therefore, a survey was conducted on November 8, 1992 among 7 of the most heavily used health authority family planning clinics (FPC) and 7 general practitioner (GP) practices which offer contraceptive services. The GP practices were located close to FPCs. 3 additional GPs were added, of which 2 were not in the health authority area, and 1 was a branch. The survey instrument, which was developed by a select steering group is presented in its entirety. A 96% response rate was achieved. Results showed a median age of 24 years among clinic attendees and an age range of 16-47 years. FPCs tended to have younger clients. There were no differences between GPs and FPCs in the number of miscarriages experienced. FPCs had a large proportion of single (40%), never-married women, while GPs had primarily married or cohabiting women patients. 94% of the GP group reported that the GP practice was their usual location for contraceptive services, while 83% in the FPC group reported the FPC as their usual location. GP use may reflect habit and clinics may attract a more mobile population or referrals. The question pertaining to the usual source of FP advice and information elicited ambiguous responses. Of the data tabulated by age, it appears that 14-16 year old were more likely to choose another FPC, whereas women in other age groups were likely to seek advice from a GP. The reasons for attending a FPC were to be able to consult a woman doctor and to obtain contraceptive supplies. Personal attention from one's own doctor was the reason given for attendance at GP groups. Both facilities reported that oral contraceptives were the most common method used. FPC tended to prescribe alternatives, particularly to young acceptors who were more likely to use oral contraceptives with a barrier method. Contraceptive knowledge is obtained wherever women normally go for advice. Both types of facilities have a continuing and complementary role.
To identify the impact of a smoking cessation programme on area-based social and ethnic inequalit... more To identify the impact of a smoking cessation programme on area-based social and ethnic inequalities in smoking rates through social and ethnic differences in enrolment and quitting. Analysis of records of 11 325 patients who enrolled in an innovative smoking cessation programme in Christchurch, New Zealand between 2001 and 2006. We compare enrolment, follow-up, quitting and impact on population smoking rates in the most and least deprived neighbourhoods and the neighbourhoods with the lowest and highest proportions of Māori. Enrolment as a proportion of the population was higher from the most deprived areas but as a proportion of neighbourhood smokers, it was lower. Enrolees from the least deprived quintile were 40% more likely to quit than those from the most deprived quintile. Smoking rates were 2.84 (2.75 to 2.93) times higher in the most deprived neighbourhoods. If the programme had not been available we estimate that this differential would have reduced to 2.81 (2.72 to 2.90). In neighbourhoods with the highest proportion of Māori, smoking rates were 2.33 (2.26 to 2.41) times higher and we estimate that without the programme smoking rates would be 2.30 (2.23 to 2.37) times higher. Although enrolees were drawn from a wide variety of backgrounds, those most likely to quit tended to reside in affluent areas or areas with a low proportion of Māori. There was no evidence that this smoking cessation programme increased or decreased inequalities within the Christchurch population. For smoking cessation programmes to have an impact on health inequalities more effort is required in targeting hard-to-reach groups and in encouraging them to quit.
General practice is a recommended setting for the delivery of smoking cessation programs. Little ... more General practice is a recommended setting for the delivery of smoking cessation programs. Little is known about the types of practice that achieve higher cessation rates. To address this gap in knowledge, we assessed the impact of general practice characteristics on the outcomes of a large scale smoking cessation intervention delivered in general practice settings. A cross-sectional study was undertaken of 7,778 participants enrolled on a structured cessation program comprising repeated brief interventions in one-to-one sessions and nicotine replacement therapy in Christchurch New Zealand, 2001-2007. We employed a logistic multilevel analysis of respondents nested in general practices with cessation at 6 months as the outcome measure. After taking into account relevant individual-level predictors (age, sex, smoking intensity) and area-level surrogates for individual predictors (socioeconomic status and access to tobacco retail outlets), there remained significant variation in quit rates between practices. This variation reduced when practice characteristics were included. Practices with a majority of male doctors and practices with fewer male patients were associated with better quit rates. Practices with large numbers of doctors were less effective in achieving cessation with heavy smokers. The effectiveness of smoking cessation programs can be influenced significantly by practice characteristics. To increase quit rates, more attention should be paid to the institutional setting of smoking cessation programs. Assessments of the effectiveness of cessation programs should give appropriate recognition to the fact that some practices may find higher quit rates more difficult to achieve.
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