Computer-based interventions for sexual health promotion: systematic review and meta-analyses

This systematic review was conducted to determine the effects of self-help interactive computer-based interventions (ICBIs) for sexual health promotion. We searched 40 databases for randomized controlled trials (RCTs) of computer-based interventions, defining 'interactive' as programmes that require contributions from users to produce personally relevant material. We conducted searches and analysed data using Cochrane Collaboration methods. Results of RCTs were pooled using a random-effects model with standardized mean differences for continuous outcomes and odds ratios (ORs) for binary outcomes, with heterogeneity assessed using the I(2) statistic. We identified 15 RCTs of ICBIs (3917 participants). Comparing ICBIs to minimal interventions, there were significant effects on sexual health knowledge (standardized mean difference [SMD] 0.72, 95% confidence interval [CI] 0.27-1.18); safer sex self-efficacy (SMD 0.17, 95% CI 0.05-0.29); safer-sex intentions (SMD 0.16, 95% CI 0.02-0.30); and sexual behaviour (OR 1.75, 95% CI 1.18-2.59). ICBIs had a greater impact on sexual health knowledge than face-to-face interventions did (SMD 0.36, 95% CI 0.13-0.58). ICBIs are effective tools for learning about sexual health, and show promising effects on self-efficacy, intention and sexual behaviour. More data are needed to analyse biological outcomes and cost-effectiveness.     

Domestic violence and abuse in gay and bisexual men attending a sexual health clinic: pilot testing of an educational support intervention for sexual health practitioners

BackgroundDomestic violence and abuse is recognised globally as a pervasive public health issue, but there is less research in relation to gay and bisexual men. This study aimed to measure the occurrence of negative and potentially abusive behaviour and associations with health problems in gay and bisexual men; and pilot test an educational intervention for practitioners to increase awareness of domestic violence and abuse and provide skills in inquiry and support.MethodsBetween Sept 21, 2010, and May 25, 2011, an anonymous Health and Relationships survey was administered to English-literate men (aged 18 years) attending a sexual health clinic in London, UK. Negative behaviour included: feeling frightened of the behaviour of a partner; having to ask permission (beyond being considerate to and checking with a partner); being slapped, hit, kicked, or physically hurt; and forced sex or sexual activity. Health problems included mental health, sexual health, and alcohol and illicit drug use. Sexual health practitioners received training on the educational intervention HERMES (HEalthcare Responding to MEn for Safety). 6 weeks after training, 21 semi-structured interviews were conducted with the practitioners to assess acceptability of HERMES, changes in awareness, and confidence in identifying and responding to gay and bisexual men who were experiencing domestic violence and abuse.FindingsOf 2657 men who attended the clinic, 1132 (42·4%) completed the survey. 532 (47·2%) self-identified as gay or bisexual. 33·9% (95% CI 24·9–37·9) of gay and bisexual men reported ever experiencing a negative and potentially abusive behaviour from a partner. Ever being frightened by a partner and having to ask a partner's permission were associated with increased odds of being anxious (odds ratio [OR] 2·5, 95% CI 2·0–3·1 and 2·7, 1·6–4·7, respectively). Being frightened of a partner, being physically hurt, and physically hurting a partner were associated with increased odds of using a class A drug in the previous 12 months (OR 2·2, 1·5–3·2; 2·3, 1·4–3·8; and 3·1, 2·3–4·2, respectively). Practitioners welcomed HERMES and felt that it raised their awareness and confidence in dealing with domestic violence and abuse among gay and bisexual men.InterpretationIn this clinical setting the occurrence of potentially abusive behaviours in gay and bisexual men was high. HERMES increased sexual health practitioners’ awareness of domestic violence and abuse and confidence in asking about abuse. The results can only be interpreted within the context of the sexual health clinic. Because of the cross-sectional design, it is not possible to determine the temporal direction of the associations between negative behaviour and health problems.FundingThis report presents independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0108-10084).     

Distribution of sexual health knowledge and attitudes in adolescent social networks: social network analysis of data from the STIs and Sexual Health feasibility study

Background

The social patterning of important precursors to sexual behaviour could help inform the potential reach of social network interventions. We aimed to investigate how peer networks might influence diffusion of sexual health messages in the context of a school-based peer-led sexual health intervention.

Childhood maltreatment and biomarkers for cardiometabolic disease in mid-adulthood: associations and potential explanations

BackgroundEvidence of the association between childhood maltreatment and risk of adult cardiometabolic disease is sparse. We investigated associations of different forms of child maltreatment with adult cardiometabolic markers and potential explanations.MethodsIn the 1958 British birth cohort, we tested associations of childhood neglect (ascertained at age 7 years and 11 years) and abuse (physical, sexual, psychological, self-reported at 45 years) with adult (45 years) cardiometabolic markers (blood pressure, lipids, glycated haemoglobin [HbA_1c]) using linear and logistic regressions. Models were adjusted, first for factors affecting measurements (eg, room temperature, postal delay of blood sample, and for women oral contraception and hormone replacement therapy) and early life factors (eg, birthweight, socioeconomic status) and second for explanatory factors (change in body-mass index from childhood to adulthood, adult socioeconomic status, lifestyles, mental health). We applied multiple imputation to missing data on neglect and covariates, and restricted analyses to individuals with observed cardiometabolic data.FindingsAmong 9349 participants (4650 men, 4699 women), 12% (1143) reported any form of abuse. Prevalence for sexual abuse was 1·6% (149), physical abuse 6·0% (565), and psychological abuse 10·0% (926), and 1627 (17·4%) had two or more indicators of childhood neglect. Childhood neglect was associated in adulthood with raised triglycerides by 3·9% (95% CI 0·4–7·4) and HbA_1c by 1·2% (0·4–2·0), and for women lower HDL by 0·05 mmol/L (0·01–0·08), after adjusting for early life covariates. Physical abuse was associated with increased risk of high LDL (odds ratio [OR] 1·24, 95% CI 1·00–1·55) and raised HbA_1c in men by 2·4% (0·6–4·2), and lower HDL in women by 0·06 mmol/L (0·01–0·12). Associations for sexual abuse were similar to those for physical abuse but 95% CIs were wide. Psychological abuse was associated with increased risk of high triglycerides (OR 1·23, 1·03–1·46) and low HDL by 0·04 mmol/L (0·01–0·07). Maltreatment was not associated with raised blood pressure. All associations disappeared after further adjustment: adult lifestyle was a key explanatory factor for most associations, adult socioeconomic status was important for associations with neglect but not abuse, body-mass index was important for neglect and physical abuse, and mental health was important for psychological abuse.InterpretationChildhood maltreatments were associated with poor lipid and HbA_1c profiles decades later in adulthood in this population cohort. Explanations for associations varied by form of maltreatment. Further work is needed on the role of life-course explanatory factors and on effective strategies to reduce or prevent long-term health consequences of maltreatment.FundingThis work was funded by the Department of Health Policy Research Programme through the Public Health Research Consortium and supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. The views expressed in this abstract are those of the authors and not necessarily those of the Department of Health. Data collection for participants at age 45 years was funded by the Medical Research Council (grant G0000934).     

Social norms and free-riding in influenza vaccine decisions in the UK: an online experiment

BackgroundNudge-based social norm messages conveying high influenza vaccination coverage levels signal a strong social norm, encouraging vaccination, but also a low risk of infection, discouraging vaccination and promoting free-riding. The complex interplay between these two signals can result in ambiguous vaccination decision-making at varying coverage levels. We aimed to measure different vaccination coverage levels’ (VCLs) effect on influenza vaccination intention through an online experiment.MethodsUK residents aged 18 years or older were eligible to participate in this online experiment and recruited via Prolific. They were stratified by gender and randomly assigned to a control group with no message (n=202) or one of seven treatment groups (n=1 163) with different messages of VCLs (ie, proportion of vaccinated people [10%, 25%, 50%, 65%, 75%, 85%, or 95%]) in the respondents’ environment. Effect on respondents’ vaccination intention was measured with self-reported intention and three elicited behaviour measures: opening an online map locating nearby private flu jab providers; time looking at this map; and downloading a calendar reminder to vaccinate. Linear regressions, probit, logistic, and double hurdle models were used, controlling for population behaviour perceptions, risk attitudes, and behavioural and socioeconomic characteristics collected through individual questionnaires.FindingsBetween May 3 and August 20, 2018, 1365 participants were eligible to participate. Those treated with coverage levels at 65% or higher reported significantly greater stated vaccination intention (greater intention 13·2% [95% CI 6·32–20·08], p<0·0001 if VCL=65%; 15·82% [8·65–23], p<0·0001 if VCL=75%; 18·12% [10·45–25·79], p <0·0001 if VCL=85%; 20·22% [11·98–28·45], p<0·0001 if VCL=95%) than the control group. These participants were also more likely to look at the map of vaccination locations (increased likelihood 14·6 percentage points [3·65–25·55], p=0·0090; 20·81 percentage points [9·73–31·88], p<0·0001; 18·4 percentage points [6·57–30·23], p=0·0023; 14·12 percentage points [1·27–26·96], p=0·031), and spent longer looking at the map (longer viewing 0·52 s [0·13–0·91], p=0·0094; 0·74 s [0·34–1·14], p<0·0001; 0·65 s [0·23–1·08], p=0·0025; 0·5 s [0·04–0·96], p=0·032) than the control group. Coverage lower than 65% did not lead to any significant differences between treatment and control groups for any of these measures. There was no significant effect of any treatment VCL on calendar download intention.InterpretationAverage vaccination intention was higher at lower coverage levels (potential social norm compliance) but lower at higher coverage levels (possible free-riding). Because this study examines vaccination intention rather than uptake and uses an online experimental design that might dampen generalisability, further research should be done. Still, policy makers should consider this curvilinear effect when designing vaccination interventions as using lower social norm messages might nudge vaccination better than extremely high messages.FundingImperial College Business School, National Institute for Health Research Health Protection Research Unit, UK Medical Research Council, Department for International Development, Medical Research Council Centre for Global Infectious Disease Analysis.     

Child maltreatment and living standards in adulthood: findings from a prospective birth cohort

BackgroundChild maltreatment (abuse and neglect) has well-established effects on mental health, but less is known about its influence on adult life economic circumstances. We aimed to establish associations of child maltreatment with such outcomes in mid-life.MethodsWe used data from the 1958 British birth cohort (n=8076) on child neglect and abuse (physical, sexual, psychological, and witnessing abuse) and adult (at age 50 years) long-term sickness absence, not in employment, education, or training (NEET), lacking assets, income-related support, poor educational qualifications, financial insecurity, manual social class, and social mobility. Logistic regression was used to assess associations with maltreatment separately and combined as a score (0, 1, ≥2) with and without adjustment for potential confounding factors (maternal age, birthweight, birth order, social class at birth, parental education, household amenities, crowding, and tenure at age 7 years). Missing values were imputed with multiple imputation chained equations.FindingsAbuse prevalence varied from 1% (n=115) for sexual abuse to 10% (776) for psychological abuse; 1208 (16%) were defined as neglected. 1506 (19%) of the population experienced one type of maltreatment, and 585 (7%) experienced two or more. All maltreatments were associated with most outcomes (eg, for physical abuse, adjusted odds ratio [OR] of long-term sickness absence was 2·33, 95% CI 1·62–3·35). There was a trend across multiple types of maltreatment and unfavourable outcomes—eg, adjusted OR for NEET increased for one and two or more maltreatments compared with no maltreatment (1·30 [1·02–1·65] and 1·72 [1·28–2·33], respectively; p_trend<0·0001). Likewise, adjusted OR for three or more unfavourable adult outcomes increased with more maltreatment compared with none (1·94 [1·59–2·37] for one and 2·23 (1·75–2·84] for two or more; p_trend<0·0001). Children who were sexually abused or neglected were less likely than those not sexually abused or neglected, respectively, to be upwardly mobile from birth to mid-adulthood (unadjusted OR 0·49 [0·30–0·81] and 0·45 [0·39–0·53]).InterpretationChild abuse was reported retrospectively in adulthood, although child neglect and potential confounding factors were ascertained prospectively and we examined a wide range of adult socioeconomic outcomes that are important because of their costs to individuals and society. That childhood maltreatments were associated with most unfavourable outcomes in mid-adulthood, has implications for the broader field of health equity. The increasing risk of poor adult outcome associated with multiple types of maltreatment suggests that they have an accumulating burden.FundingThis work was supported by the Department of Health Policy Research Programme through the Public Health Research Consortium. The views expressed in this abstract are those of the authors and not necessarily those of the Department of Health.     

Cardiovascular disease in the homeless: a systematic review of observational and interventional studies

BackgroundCardiovascular disease causes excess mortality and morbidity in socially excluded (inclusion health) populations. However, no specific guidelines exist for the treatment of cardiovascular disease in these individuals, including homeless populations. We aimed to better understand the disease burden and to identify evidence-based interventions in this setting by reviewing studies examining targeted interventions and prevalence of cardiovascular disease in homeless individuals.MethodsIn this systematic review, we searched Embase for observational and interventional studies of cardiovascular disease in homeless populations published on or before Dec 19, 2018, using the keywords “heart diseases”, “adrenergic beta-antagonists”, “cardiotonic agents”, “cardiovascular diseases”, “cardio-renal syndrome”, “hypertension” and “homeless [population]”. Two independent reviewers selected eligible articles and extracted relevant data, and used the Newcastle-Ottawa Scale to grade the quality of studies. The main outcome, assessed by a random-effects meta-analysis, was prevalence of cardiovascular disease (International Classification of Diseases-10 definition).FindingsOf 273 full-text articles that were retrieved, 17 (six case-control, 11 cohort) met the inclusion criteria, none of which considered interventions for cardiovascular disease. 13 (76%) of 17 were high quality, and all were based in Europe or North America, including 765 459 individuals, of whom 32 721 were homeless. 12 (71%) of 17 studies were published before 2011. Homeless individuals were more likely to have cardiovascular disease than were non-homeless individuals (pooled odds ratio [OR] 2·96 [95% CI 2·80–3·13]; p<0·0001; p_{heterogeneity}<0·0001). North American homeless individuals were more likely to have cardiovascular disease (pooled OR 3·07 [2·90–3·25]; p<0·0001; p_{heterogeneity}=0·0070) than their European counterparts (pooled OR 2·15 [1·81–2·54]; p<0·0001; p_{heterogeneity}=0·125). Compared with non-homeless individuals, hypertension was more likely in homeless people (pooled OR 1·38–1·09, 1·75; p=0·0070; heterogeneity p=0·94.InterpretationHomeless populations are at increased risk of cardiovascular disease. However, studies to-date are limited in number, geography and contemporary relevance with no interventional studies and considerable heterogeneity between existing studies. The increased burden of cardiovascular disease in homeless populations requires better characterisation and interventions need to be designed and tested urgently. Cardiovascular disease needs to be studied further in this setting if integrated care in homeless individuals is to become a reality.FundingNational Institute of Health Research Programme Development Grant (RP-DG-0117–10003).     

Determinants in early adulthood of leisure-time physical inactivity stability and change in mid-life: findings from a prospective birth cohort

BackgroundLeisure-time physical inactivity has a high prevalence and associated disease burden. Information about factors that affect inactivity stability and change is needed. We aimed to establish whether early adult factors predict inactivity patterns over subsequent decades in mid-life.MethodsThe 1958 British birth cohort is a nationwide follow-up study of all births during 1 week in March, 1958. Leisure-time inactivity in 12 271 participants was self-reported as activity (eg, walking, swimming) of less than once a week at ages 33 and 50 years. Associations of early adult (23–33 years) factors with four patterns between the ages of 33 and 50 years (never inactive, persistently inactive, deteriorating, or improving) were assessed by multinomial logistic regression, with and without adjustment for childhood factors. Missing values were imputed with multiple imputation chained equations.Findings3863 adults (32%) were inactive at 33 years; 3791 (31%) were inactive at 50 years. 4257 (35%) had changed inactivity status between 33 and 50 years (2093 [17%] deteriorating, 2164 [18%] improving). Relative risk ratios for factors associated with persistent versus never inactive were: physically limiting illness 1·21 per number of ages exposed—ie, per increase in scale [0, 1, 2] for each age [23 years and 33 years] exposed—(95% CI 1·04–1·42); obesity per number of ages exposed 1·30 (1·11–1·51), perceived underweight versus perceived right weight 1·31 (1·06–1·62), attained height per 5 cm 0·93 (0·89–0·97), depression per number of ages exposed 1·32 (1·18–1·47), education per decrease on a 5-point scale 1·30 (1·21–1·40), and neighbourhood (0·68 [0·54–0·86], 0·62 [0·49–0·78], and 0·84 [0·72–0·99] in suburbs and service centres, rural areas and seaside resorts, and growth areas vs stable industrial areas, respectively). No associations were observed for social class, cohabitation, employment, and parenthood. Associations for inactivity deterioration (vs never) were similar to those for persistently inactive. Only two factors were associated with inactivity improvement—parenthood (although associations varied for number of children at 23 years and 33 years) and neighbourhood. Associations remained, albeit attenuated, after adjustment for childhood factors.InterpretationAlthough our study of leisure-time inactivity is based on self-report, repeat, prospective data spanning decades provides a rare opportunity to investigate an important health determinant that is amenable to modification. Adult inactivity status changes are not uncommon (35% changed between the ages of 33 and 50 years), providing opportunities for behaviour interventions. Early adult factors predicted persistence of inactivity and deterioration; fewer factors predicted improvement. The neighbourhood of young adults had long-lasting associations with inactivity patterns.FundingThis work was supported by the Department of Health Policy Research Programme through the Public Health Research Consortium. The views expressed in this abstract are those of the authors and not necessarily those of the Department of Health.     

Premature mortality in adult survivors of child abuse and neglect: a nationwide birth cohort study

BackgroundChild neglect and abuse are not uncommon. Both are associated with deleterious outcomes in adulthood, but there is sparse evidence on the association between such trauma and premature adult mortality. We aimed to establish whether different types of child maltreatments were associated with all-cause mortality in mid-adulthood and examined potential intermediaries of this association.MethodsUsing the 1958 British birth cohort (n=9310), we examined associations between child neglect (prospectively recorded at years 7 and 11 of age) and abuse (physical, psychological, witnessing and sexual; self-reported at years 44–45 of age) with all-cause mortality, using Cox proportional hazard models adjusted for early-life covariates and other maltreatment types. We tested interactions between each maltreatment type and sex; there was little evidence of effect modification (p_interaction>0·001), hence models also adjust for sex. Mortality follow-up was between 2002–03 and December 2016 (participants aged 44–45 to 58 years). Death was ascertained from the National Health Service Central Register (n=296) or from survey updates (n=16). Potential intermediaries included: adult social factors, health behaviours, adiposity, mental health, cardiometabolic markers, and growth (height) at years 7 to 45 of age. Missing data were imputed via multiple imputation.FindingsChild maltreatment prevalence varied from 1·6% (n=149; sexual abuse) to 11% (n=1000; physiological abuse); 77% (n=6536) reported no maltreatment. Neglect and abuse (physical and sexual) were associated with increased risk of premature death, independent of covariates and other maltreatment types; adjusted hazard ratios (HRs) were 1·47 (95% CI 1·05–2·05) for neglect, 1·73 (1·10–2 ·71) for physical abuse, and 2·60 (1·49–4·52) for sexual abuse. Associations for neglect and physical abuse disappeared after adjustment for adult health behaviours, and, for neglect only, social factors; other intermediaries had little effect on these associations. Sexual abuse associations were largely unexplained by examined intermediaries. Risk of all-cause mortality increased with the number of maltreatments (versus none): adjusted HRs were 1·44 (1·07–1·93) for one maltreatment and 2·04 (1·45–2·87) for at least two maltreatments.InterpretationChild neglect and physical and sexual abuse are associated with increased risk of premature mortality in mid-adulthood. Our findings highlight the importance of preventing specific child maltreatments and of supporting survivors to potentially mitigate differences in premature mortality. Child abuse was reported retrospectively and estimated associations for sexual abuse might be imprecise due to low prevalence. However, child neglect, potential confounders, and mediators were ascertained prospectively.FundingUS National Institute on Aging, the UK Economic and Social Research Council, the UK Biotechnology and Biological Sciences Research Council, and the UK National Institute for Health Research Biomedical Research Centre.     

“The Mould that Changed the World”: a quantitative and qualitative evaluation of knowledge and behavioural change in children in the UK following participation in a musical about antimicrobial resistance

BackgroundA primary school musical—“The Mould that Changed the World”—was developed as a unique public engagement strategy to combat antimicrobial resistance (AMR) by engaging children in the story of the discovery of antibiotics, the risks of drug-resistant infections, and the importance of prudent antibiotic use.MethodsThe musical intervention was implemented in two UK primary schools. Parental consent was obtained for all participating children. All 182 participating children, aged 9–11 years, were given an online questionnaire in the classroom before rehearsals began and at 2 weeks after performance with a 6-month evaluation in one school. The effect of the musical was analysed using generalised linear models to control for confounding factors. For the qualitative evaluation, 15 participating children were selected randomly from each school to take part in semi-structured focus groups (n=5 per group) before rehearsals began and 2 weeks after performance. This study was approved by the University of Edinburgh research governance office as an evaluation of an intervention.FindingsConsistent with other intervention studies, knowledge gain was shown with children being more likely to answer questions on key messages of the musical correctly 2 weeks after performance (n=161) compared with the pre-rehearsal questionnaire (n=180; odds ratio 4·63 [95% CI 2·46–9·31], p<0·0001 for knowledge that bacteria can become resistant to antibiotics; 3·26 [1·75–6·32], p=0·00014 for knowledge that antibiotic resistant infections can be life threatening; 2·16 [1·39–3·38], p=0·00059 for knowledge that prudent use of antibiotics will halt rise of antibiotic resistant infections). Long-term knowledge gain was shown by a consistent level of correct answers on key messages between 2 weeks (response rate 95%, n=89) and 6 months after the musical (response rate 71%, n=67). Following the musical children participating in the focus groups (n=30) articulated a greater understanding of AMR and the risks of antibiotic overuse. They discussed intention to minimise personal antibiotic use and influence attitudes to antibiotics in their family and friends.InterpretationAlthough only evaluated in two schools, this study shows that initiatives such as musical theatre can improve both short-term and long-term knowledge in children. It shows a hitherto infrequently reported change in attitude and intention to behaviour change in children at an influential age for health beliefs. This unique public health tool has the potential for national roll-out in primary schools across the UK.FundingBritish Society of Antimicrobial Chemotherapy.     

What predicts food insecurity? An online survey

BackgroundFood poverty (inability to afford or access a healthy diet) is a public health emergency, manifesting as a short-term dilemma of accessing food alongside longer-term effects of relying on poor nutritional quality foods to satiate hunger and worrying about food running out because of lack of money. The study aimed to predict what factors might predispose people to this condition by enquiring about respondents’ food poverty experiences.MethodsWe did an online survey (from September to November, 2018) to measure food poverty experiences alongside demographics and self-reported health evaluation in the UK (n=944 respondents). We used a snowball sampling technique, and the researchers and stakeholders promoted the survey by acting as gatekeepers on social media. Complementary paper surveys provided remote access to the research. Inclusion criteria required respondents be the primary householder or main earner (and be aged 18 years or older). We did a binary logistic regression analysis to test if age (18–25, 26–35, 36–45, 46–55, 56–65, ≥66 years old), gender (male, female, other), location (urban, rural), household size, number of children (<18 years old), income (<£10 000, £10 000–19 999,….£100 000–150 000, ≥£150 000), home ownership status (owned, rented), employment (unemployed, employed), education, and self-reported health status predicted worry about running out of food in the past 12 months (Food and Agriculture Organization's Food Insecurity Experience Scale). Ethics approval was granted, and participants gave implied informed consent.FindingsUnweighted case summaries indicated slightly more male respondents (51·8%), and one in five (21·3%) respondents were economically inactive. 8% had a total annual household income of less than £10 000. One in 14 (7·4%) self-reported poor health status. Two-fifths (41·9%) had children living at home. Importantly, 24% of the sample worried about food running out. The model (χ²_{(10, N=944)}=155·158, p<0·0001) significantly distinguished between households that were and were not food poor. Respondents who self-reported poorer health status were more likely to be in food-poor households (odds ratio [OR]=2·10, 95% CI 1·61–2·72; p<0·0001) as were those who had more children (1·52, 1·20–1·93; p=0·001); but food poverty was less likely to be reported in respondents who were older (0·73, 0·58–0·92; p=0·007), in those who owned their property (0·45, 0·25–0·81; p=0·008), and in those who had higher household incomes (0·74, 0·62–0·88; p=0·001). The associations between food poverty and the remaining variables were not significant.InterpretationPersonal and household circumstances can predict food poverty. Given future public health consequences, these predictors could usefully inform targeted interventions for risk profiling vulnerable citizens.FundingUlster University Civic Impact Research Fund.     

Prevalence of finding sexual partners online and associations with sexual behaviour and sexual health outcomes: a British national probability survey

BackgroundOnline venues provide opportunities to facilitate sexual encounters, but the extent to which finding partners online is associated with risky sexual behaviour and poor sexual health outcomes is unclear; much of the research to date has focused on subpopulations, or convenience samples. We aimed to describe individuals' use of the internet to find sexual partners in a representative sample of the British population.MethodsThe third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) was a cross-sectional probability survey of 15 162 adults aged 16–74 years, which used computer-assisted personal-interview and self-interview, undertaken during 2010–12. The sample was weighted to account for selection probability and non-response, and corrected for differences in demographics according to the UK 2011 census. We estimated the prevalence of, and identified factors associated with, finding sexual partners online in the past year among 5698 men and 8198 women who reported sexual experience ever.FindingsUse of the internet to find sexual partners in the past year was reported by 5·2% of men (95% CI 4·7–5·8) (unweighted n=389) and 2·4% of women (2·1–2·8) (unweighted n=249), and was associated with younger age. After adjustment for age, individuals reporting a non-heterosexual identity (adjusted odds ratio for men 8·87, 5·95–13·22; for women 3·56, 2·20–5·78) were more likely to report finding partners online. This outcome was also associated with reporting sexual risk behaviours including sex without a condom with two or more partners (men 5·24, 3·71–7·39; women 6·36, 4·25–9·53), reporting five or more partners (11·19, 6·36–19·67; 17·44, 7·32–41·52), and reporting a new partner (13·27, 9·49–18·54; 14·93, 9·97–22·37). Sexual health clinic attendance (men 1·92, 1·18–3·15; women 2·25, 1·08–4·69), HIV testing (2·91, 1·91–4·44; 1·82 1·09–3·03), and diagnoses of sexually transmitted infections (men only 2·19, 1·17–4·12) were more common among individuals reporting finding partners online after adjustment for age and number of partners.InterpretationFinding partners online was strongly associated with markers of sexual risk and health-service uptake. Online opportunities have increased since 2010–12, so these data might underestimate the importance of this social phenomenon for public health and control of sexually transmitted infections. Given the cross-sectional survey design, neither directionality nor causality can be inferred.FundingNatsal-3 was supported by grants from the Medical Research Council (G0701757) and the Wellcome Trust (084840), with contributions from the Economic and Social Research Council and Department of Health.     

Walking to improve cardiovascular health: a meta-analysis of randomised control trials

BackgroundPhysical inactivity causes approximately 17% of premature mortality in the UK. Walking offers a promising method for lowering risk of cardiovascular disease at population level, though a recent synthesis of evidence is lacking. This study aimed to conduct a meta-analysis of randomised controlled trials that have assessed the effect of walking on risk factors for cardiovascular disease in previously inactive adults.MethodsWe searched PubMed, Web of Science, ScienceDirect, and the Cochrane Central Register of Controlled Trials for studies published in English between Jan 1, 1970, and May 31, 2012, using the following search terms: "walking", "exercise", "health", and "cardiovascular risk". Two authors identified randomised controlled trials of interventions (>4 weeks' duration) that included at least one group with walking as the only treatment and a comparator no-exercise group. Participants were inactive but otherwise healthy at baseline. Pooled results were reported as weighted mean treatment effects and 95% CIs in a random effects model.Findings32 articles reported the effects of walking interventions on risk factors for cardiovascular disease in participants aged 30–83 years. Mean length of interventions was 18·7 weeks (range 8–52). Duration of walking was 20–60 min on 2–7 days per week. Walking interventions reduced systolic and diastolic blood pressure (?3·6 mm Hg, 95% CI ?5·19 to ?1·97; ?1·5 mm Hg, ?2·83 to ?0·26). Interventions also improved waist circumference (?1·5 cm, ?2·34 to ?0·68), weight (?1·4 kg, ?1·75 to ?1·00), body fat (?1·2%, ?1·70 to ?0·73), and body-mass index (BMI) (?0·5 kg/m², ?0·72 to ?0·35). Walking improved aerobic fitness (3·2 mL/kg per min, 95% CI 2·57 to 3·80) but did not alter blood lipids. Significant heterogeneity (I² statistic) was noted for aerobic fitness, BMI, weight, and percentage body fat. Many studies did not provide sufficient information to make firm judgments about risk of bias.InterpretationThese findings support the important role of walking in physical activity for health promotion. Health professionals involved in the primary prevention of cardiovascular disease should prescribe walking confident of the benefits it can provide in fitness, blood pressure, and adiposity.FundingFunding was received from the Mary Immaculate College Research Directorate Seed Funding Scheme for assistance with data extraction. The funder had no role in the study.     

Diabetes and higher HbA1c levels are independently associated with adverse renal outcomes in inpatients following multiple hospital admissions

ObjectiveTo assess the association between glycaemic status prior to the first hospital presentation with developing adverse renal outcomes overtime in patients with multiple hospital re-admissions.DesignA prospective observational cohort study.ParticipantsAll inpatients aged ≥54 years admitted between 2013 and 16 to a tertiary hospital.Main outcomesWe prospectively measured HbA1c levels in all inpatients aged ≥54 years admitted between 2013 and 16. Diabetes was defined as prior documented diagnosis of diabetes and/or HbA1c ≥6.5% (47·5 mmol/L). Included patients had ≥ two admissions (at least 90 days apart), baseline estimated glomerular filtration rate (eGFR) >30 ml/min/1·73m² and no history of renal replacement therapy. We assessed several renal outcomes: (a) 50% decline in eGFR; (b) rapid decline in renal function (eGFR decline >5 mL/min/1·73m²/year) and (c) final eGFR<30 ml/min/1·73m².ResultsOf 4126 inpatients with a median follow-up of 465 days (254, 740), 26% had diabetes. The presence of diabetes was associated with higher odds of (a) 50% decline in eGFR (OR = 1·42;95% CI:1·18–1·70;p < 0·001); (b) rapid decline in renal function (OR = 1·40;95%CI:1·20–1·63;p < 0·001), and (c) reaching eGFR<30 ml/min/1.73m² (OR = 1·25;95%CI:1·03–1·53;p < 0·05). Every 1% (11 mmol/L) increase in baseline HbA1c was associated with significantly greater odds of (a) >50% decline in eGFR (OR = 1·07;95% CI:1·01–1·4;p < 0·05) and (b) rapid decline in renal function (OR = 1·11;95% CI:1·05–1·18;p < 0·001).ConclusionsIn patients with ≥two admissions, the presence of diabetes and higher HbA1c levels were strongly and independently associated with adverse renal outcomes at follow up. Such patients are at high risk of relatively rapid deterioration in renal function and a logical target for structured preventive interventions.     

The mortality of patients with severe mental disorders and the impact of community management: a community-based prospective study in Sichuan,China

Background

The mortality of people with mental illness is consistently higher than that of the general population according to current literature in developed countries. However, evidence in China is scarce. Patients with severe mental disorders (SMD) have been managed in the community since 2009 in China, but there has been no study of mortality, or the impact of community management on mortality, in this patient population. This study aims to provide preliminary empirical evidence.

Trends in mental health and wellbeing among children and young people in the UK: a repeated cross-sectional study, 2000–14

BackgroundIncreasing concerns have been raised by professionals in education, health, and other sectors that mental health and wellbeing among children and young people in the UK might be deteriorating, but few nationally representative studies have tested this hypothesis. The objective of this study was to investigate trends in mental health and wellbeing among participants aged 4–24 years in UK national health surveys, 2000–14.MethodsWe used data from national health surveys of four UK countries: England (15 surveys, n=67 386, unweighted), Scotland (8, 16 862), Wales (8, 17 677), and Northern Ireland (1, 339). Trends were evaluated for children aged 4–12 years with the Strengths and Difficulties Questionnaires (SDQ) (parent or carer report) and for young people aged 16–24 years with the General Health Questionnaire (GHQ12) and Warwick Edinburgh Mental Health and Wellbeing Scores (WEMWBS) (self-report for both instruments). We assessed changes over time within countries using weighted t tests of the earliest and latest data for each country and linear regression models using all data.FindingsThere were no significant changes in SDQ scores in England, Wales, or Scotland. The proportion of Scottish parents reporting emotional problems was lower in 2014 than in 2003 (weighted proportions 43/908, 4·7% [95% CI 3·3–6·1] vs 175/1819, 9·6 [8·3–11·0]; p<0·001), but no significant overall trend in any country was seen. According to the GHQ scores, prevalence of mental health problems was higher in Scotland in 2014 than in 2003 (103/570, 18·1% [14·9–22·1] vs 117/931, 12·6 [10·4–14·7]; p=0·004), but unchanged in England. Regression analyses showed no significant trend. Wellbeing scores in England measured by WEMWBS were unchanged but were lower in Scotland in 2014 than in 2008 (49·5 [48·9–50·2] vs 50·5 [50·0–51·0], p=0·04). There was no significant overall trend.InterpretationPrevalence of mental health problems among children and young people has been largely stable in England and Wales over the past 14 years. In Scotland, no significant linear trends were identified, but the most recent data show fewer emotional problems in younger children along with more mental health problems, and decreased wellbeing among young adults.FundingNone.     

Assessment of changes in the burden of Chlamydia trachomatis infection in the context of widespread opportunistic chlamydia screening: Pgp3 seroprevalence measured in a series of nationally representative cross-sectional household surveys

BackgroundOpportunistic screening of people aged under 25 years for genital Chlamydia trachomatis infection (chlamydia) was nationally implemented in England in 2008, but its impact is poorly understood. Antibodies to C trachomatis persist after infection, thus providing a marker of past infection. We aimed to explore the effect of screening on cumulative incidence of chlamydia (incidence of infection by a given age), as measured by C trachomatis antibodies.MethodsAnonymised serum samples from participants in the nationally representative Health Surveys for England (HSE) were tested for C trachomatis antibodies using two novel in-house Pgp3 ELISAs, which have demonstrated superior sensitivity to commercial assays. Determinants of being seropositive were explored with logistic regression among women (n=1402) and men (1119) aged 16–44 years in 2010–12 (years when questions about sexual behaviour were included in the survey). Seroprevalence trends among 16–24-year-old women (n=3361) were investigated over ten timepoints from 1994 to 2012.FindingsDuring 2010–12, Pgp3 seroprevalence among participants aged 16–44 years was 24·4% (95% CI 22·0–27·1) in women and 13·9% (11·8–16·2) in men. Seroprevalence increased with age (up to 33·5% [27·5–40·2] in 30–34-year-old women; 18·7% [13·4–25·6] in 35–39-year-old men) and with years since first sexual intercourse (38·2% [32·0–44·7] in women and 22·3% [16·2–29·8] in men aged 15–19 years). Total number of lifetime sexual partners and younger age at first sex were significantly associated with being seropositive (>10 lifetime sexual partners vs 1–4: odds ratio 3·84 women [95% CI 2·68–5·51], 5·95 men [3·41–10·35]; <16 years old at first sex vs >16: 2·26 women [1·61–3·16], 2·14 men [1·41–3·24]). 76·7% of seropositive 16–24-year-olds had never been diagnosed with chlamydia: among women, seroprevalence did not differ between the first (1994–96) and second (2001–02) periods sampled (prevalence ratio 1·04, 0·87–1·25); a non-significant decline was observed from 2008 to 2012 (prevalence ratio per year 0·94, 0·84–1·05).InterpretationOur application of Pgp3 ELISAs demonstrates a high lifetime risk of chlamydia among women and that a large proportion of infections go undiagnosed. A decrease in age-specific cumulative incidence after national implementation of opportunistic chlamydia screening has not yet been demonstrated. We propose that these assays be used more widely to assess the effect of chlamydia control programmes.FundingThe Health Survey for England was funded by the Health and Social Care Information Centre. Testing of stored serum samples was funded by the Health Protection Agency (now Public Health England). The funders played no part in the design, conduct, analysis, or reporting of this study, or in the decision to submit the abstract for publication.     

Comparative effectiveness of exercise interventions for low back pain: a systematic review and network meta-analysis of 41 randomised controlled trials

Background

Low back pain is a major health concern in China because of its high prevalence among the general population. Exercise is universally recommended as a core treatment to reduce the symptoms, but the relative efficacy of different types of exercise have not been evaluated, and the most appropriate exercise intervention is still unknown. We therefore aimed to compare and rank the effectiveness of different exercise interventions in relieving pain and improving function in patients with low back pain using a network meta-analysis.

Patient and health-care factors associated with potentially missed acute deterioration in primary care: a retrospective observational study of linked primary and secondary care data

BackgroundIn the UK, the majority of patient contact with health services occurs in primary care. Most of these contacts are uncomplicated; however, patient safety incidents (eg, failure to recognise patient deterioration) can occur. We aimed to explore patient and health-care factors associated with a self-referred admission, in patients with deteriorating health who consulted a general practitioner (GP).MethodsIn this observational study, we identified patients who had consulted a GP in the 3 days before an unplanned admission (indication of deterioration) between April 1, 2014, and Dec 31, 2017, in England, using the Clinical Practice Research Datalink with linkage to inpatient hospital admissions and emergency department data. We applied a multivariable, multilevel logistic regression model (generalised estimating equations) to investigate factors associated with self-referral (ie, patient age and existing health conditions, GP consultation, deteriorating health condition, and previous health service use) compared with other-referred unplanned admissions (eg, GP-referrals). Self-referred admission, as a composite measure, was defined as an unplanned admission via the emergency department (inpatient data) recorded as a self-referral in the corresponding emergency department record. We investigated all diagnoses and a subset of commonly reported missed conditions: sepsis, pulmonary embolism, urinary tract infections, and ectopic pregnancies in women.FindingsOf 405 878 unplanned admissions, 116 094 (28%) patients had contact with a GP 3 days before admission. The proportion of self-referred admissions varied by region (4189 [31%] of 13 639 inpatient admissions in London vs 1721 [12%] of 14 641 inpatient admissions in south west England), age, deteriorating health, and existing health conditions. Patients with sepsis or a urinary tract infection were more likely to self-refer than patients with other conditions (adjusted odds ratio [OR] 1·10, 95% CI 1·02–1·19 for sepsis; 1·09, 1·04–1·14, for urinary tract infection). GP appointment length was associated with a self-referred admission: a 5 min increase in consultation duration decreased the risk of self-referral by 6% (OR 0·94, 0·91–0·97). Telephone consultations, comorbidity, and previous health service use were also associated with self-referred admission.InterpretationDifferentiating deterioration from self-limiting conditions is difficult for GPs, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The negative association between GP consultation duration and self-referral supports demand for longer GP consultations. However, more research is needed to investigate the underlying mechanism between GP consultation time and referral.FundingNational Institutes for Health Research.