Service evaluation of a pilot to improve primary care sexual health services in England implemented using a stepped wedge design

BackgroundSexual health service provision in primary care is an essential component to universal provision of sexual and reproductive health services. However the offer of these services is not consistent. The 3Cs & HIV was a national pilot that combined educational workshops with posters, testing performance feedback, and continuous support from a specialist trainer. The aim was to improve awareness and skills of staff to increase rates of chlamydia screening in the population at highest risk (men and women aged 15–24 years) and to provide condoms with contraceptive information plus HIV testing according to national guidelines.MethodsThe pilot used a stepped wedge design over three phases from Aug 1, 2013, to Sept 30, 2014. Chlamydia testing and diagnosis rates in the control (pretraining) and intervention (post-training) periods were compared by use of a multivariable negative binomial regression model with general practice fitted as a random effect. Owing to the stepped wedge design, the number of months contributing to the control and intervention periods differed depending on which phase the general practice was allocated to and when the practice received training. Characteristics of general practices participating were included in the model. Practices were not paid for the intervention. The Research Governance Coordinator for Public Health England confirmed that no ethics approvals were needed for this study.FindingsThe 460 participating practices conducted 26 021 tests in the control period and 18 797 tests during the intervention period. Intention-to-treat analysis showed decreased median number of tests and diagnoses per month per practice after receiving training (2·68 tests before training [IQR 1·00–4·77] vs 2·67 after training [1·10–4·90]; 0·14 diagnoses before training [0–0·30] vs 0·13 after training [0–0·27]). Adjusted multivariable regression analysis showed no significant change in overall testing or diagnoses (incidence rate ratio [IRR] 1·01, 95% CI 0·96–1·07 and 0·98, 0·84–1·15, respectively). Testing increased significantly in 148 practices where payment was already in place before the intervention (IRR 2·12, 95% CI 1·41–3·18).InterpretationThis large national pilot found that educational support sessions to increase chlamydia screening in primary care were only effective in practices that already receive payment for chlamydia screening. 3Cs & HIV training might be a useful way to make better use of the resources already available. However this intervention will not increase national testing rates substantially. Although increases found in subgroups were statistically significant, they were still relatively small in magnitude.FundingThe 3Cs & HIV pilot was funded by Public Health England and was part of the Chlamydia Testing Training in Europe (CATTE) project. CATTE is part funded by a Leonardo Transfer of Innovation grant as part of European Union Lifelong Learning Programme.     

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.     

Future trends in morbid obesity in England,Scotland, and Wales: a modelling projection study

BackgroundThe prevalence of morbid obesity is increasing worldwide, with numbers doubling in the past 20 years. Morbid obesity (body-mass index [BMI] ≥40 kg/m²) is associated with a high risk of chronic disease, such as type 2 diabetes, coronary heart disease, stroke, mental illness, and some cancers, and increased all-cause mortality rates. In addition, individuals with morbid obesity have more complex health issues and challenges in the health-care system than do those with a lower BMI. A recent global study reported a prevalence range from less than 0·1% in Chinese women to 23·1% in American women. Morbid obesity accounts for 24–35% of all obesity-related costs, presenting a substantial burden on the economy and health service. We aimed to project trends in morbid obesity to 2035 in adults in England, Scotland, and Wales.MethodsMorbid obesity rates for the three countries were obtained from the Health Survey for England (1993–2015) and Welsh Health Survey (2004–14) through the UK data service online resource and from the Scottish Health Survey team directly (2003, 2008–14). Rates were determined for men and women aged 16 and older separately (in 5 year age-groups). A multivariate non-linear regression was fitted to the data to project BMI trends. Building on previous models used by the UK Health Forum, we used BMI prevalence data, with age and sex as covariates. Validation was not done for this study, but has been done in earlier work with the Foresight study.FindingsMorbid obesity prevalence is projected to vary from 4% (in Scottish men aged 16–24 years old) to 54% (in English men aged 75 and older) by 2035. England and Wales are projected to have higher rates of morbid obesity in men than in women whereas the opposite is true of Scotland. Of the three countries, Wales is projected to have the highest levels of morbid obesity. Additional work is looking at population data.InterpretationThe prevalence of morbid obesity is set to increase to 2035 across England, Scotland, and Wales. This increase will have serious health and financial implications for the health service and population. The next stage will be to run a microsimulation to test the impact of morbid obesity on future disease burden.FundingNone.     

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.     

How common are chlamydia-related bacteria in early pregnancy and are they associated with miscarriage or preterm birth? Community-based prospective cohort study

BackgroundSerological case-control studies suggest that certain chlamydia-related bacteria (Chlamydiales) that cause cows to miscarry might do the same in human beings. Included in the order Chlamydiales are Waddlia chondrophila, Chlamydophila abortus, and Chlamydia trachomatis. We aimed to investigate the prevalence of Chlamydiales in pregnant women, and possible associations with miscarriage or preterm birth.MethodsWe tested stored urine samples from a carefully characterised cohort of 847 pregnant women recruited at mean 49·3 (SD 10·1) days’ gestation from 37 general practices in London, UK. Previous repeat testing of samples positive for Mycoplasma genitalium confirmed bacterial DNA integrity after storage. W chondrophila and pan-Chlamydiales specific real-time PCRs targeting the 16s rRNA gene were used to test samples. Samples positive on either of the two PCRs were subjected to DNA sequencing and Chlamydia trachomatis PCR. Outcomes were compared between infected and uninfected women with Fisher's exact test. Ethics review was conducted by Wandsworth, Croydon, and Riverside Research Ethics Committees.FindingsThe overall prevalence of Chlamydiales was 4·3% (36/847, 95% CI 3·0–5·8). Prevalence of W chondrophila was 0·6% (5/847, 0·2–1·4), Chlamydia trachomatis 1·7% (14/847, 0·9–2·8), and other Chlamydiales species 2·0% (17/847, 1·2–3·2). Infection with Chlamydia trachomatis (but not with other Chlamydiales or W chondrophila) was more common in women younger than 25 years, of black ethnicity, or with bacterial vaginosis. Follow-up was 99·9% (846/847) at 16 weeks’ gestation and 89·6% (759/847) at term. No infection was significantly associated with miscarriage (prevalence 10%, 84/827) or spontaneous preterm birth before 37 weeks’ (4%, 23/628) but numbers were small. One of three (33%) followed-up women infected with W chondrophila had a preterm birth compared with 22 (4%) of 625 uninfected women (p=0·11). Sequencing of 25 samples that were positive on W chondrophila or pan-Chlamydiales PCR revealed seven samples (28%) positive for Chlamydiales bacterium sequences that have been associated with respiratory tract infections in children.Interpretation4% of newly pregnant women tested positive for Chlamydiales, including species known to be pathogenic in mothers and neonates. Higher rates might have been found in vaginal samples and the study lacked power to test associations. Although W chondrophila might be associated with preterm birth, the prevalence was very low in this urban, community-based sample, suggesting that screening is unlikely to be cost-effective in such a population.FundingMedical Research Council.     

The prevalence of Chlamydia trachomatis infection in Australia: a systematic review and meta-analysis

Background

Chlamydia trachomatis is a common sexually transmitted infection in Australia. This report aims to measure the burden of chlamydia infection by systematically reviewing reports on prevalence in Australian populations.

Methods

Electronic databases and conference websites were searched from 1997?C2011 using the terms ??Chlamydia trachomatis?? OR ??chlamydia?? AND ??prevalence?? OR ??epidemiology?? AND ??Australia??. Reference lists were checked and researchers contacted for additional literature. Studies were categorised by setting and participants, and meta-analysis conducted to determine pooled prevalence estimates for each category.

Results

Seventy-six studies met the inclusion criteria for the review. There was a high level of heterogeneity between studies; however, there was a trend towards higher chlamydia prevalence in younger populations, Indigenous Australians, and those attending sexual health centres. In community or general practice settings, pooled prevalence for women <25?years in studies conducted post-2005 was 5.0% (95% CI: 3.1, 6.9; five studies), and for men <30?years over the entire review period was 3.9% (95% CI: 2.7, 5.1; six studies). For young Australians aged <25?years attending sexual health, family planning or youth clinics, estimated prevalence was 6.2% (95% CI: 5.1, 7.4; 10 studies) for women and 10.2% (95% CI: 9.5, 10.9; five studies) for men. Other key findings include pooled prevalence estimates of 22.1% (95% CI: 19.0, 25.3; three studies) for Indigenous women <25?years, 14.6% (95% CI: 11.5, 17.8; three studies) for Indigenous men <25?years, and 5.6% (95% CI: 4.8, 6.3; 11 studies) for rectal infection in men who have sex with men. Several studies failed to report basic demographic details such as sex and age, and were therefore excluded from the analysis.

Conclusions

Chlamydia trachomatis infections are a significant health burden in Australia; however, accurate estimation of chlamydia prevalence in Australian sub-populations is limited by heterogeneity within surveyed populations, and variations in sampling methodologies and data reporting. There is a need for more large, population-based studies and prospective cohort studies to compliment mandatory notification data.     

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).     

Factors affecting young people's preferences for emerging technologies for chlamydia testing and treatment: a discrete choice experiment in England

BackgroundTechnological advances offer opportunities to redesign existing chlamydia screening and testing, and treatment pathways, to improve screening uptake and the proportion of positive individuals successfully treated. Innovations underway include self-tests networked through mobile phones, which could be combined with online clinical care and other non-face-to-face care pathways. Evidence of young people's preferences should be key to informing optimum service redesign. We aimed to quantify factors affecting young people's preferences for emerging chlamydia testing and treatment pathway options in a discrete choice experiment (DCE).MethodsMethods used to select attributes and levels for the DCE included a systematic literature review, four focus groups (staged recruitment to include spread in age range 16–24 years and other demographic characteristics), and four expert groups of clinicians and researchers. The literature review sought stated preference studies for testing and treatment of sexually transmitted infections (STI) published before Dec 31, 2015. Studies were published in English, and included one or more aspects of mainstream STI testing and treatment for any STI, undertaken in an Organisation for Economic Co-operation and Development high-income country. Key search terms included stated preference, stated choice, DCE, contingent valuation, and conjoint analysis. A draft questionnaire was tested in a pilot (n=9). The final questionnaire (including 25 pairwise choices with opt-out) was completed online by a national panel of young people aged 16–24 years across England (YouthSight). Analysis used multinomial logit models and included validity checks.FindingsThere were 1230 respondents (response rate 73%). The strongest attribute affecting preferences was chlamydia test accuracy (odds ratio [OR] 3·24, 95% CI 3·13–3·36), followed by time to result (1·81, 1·71–1·91). Respondents showed a preference for remote chlamydia testing options (self-testing, self-sampling, postal testing) over attendance at a testing location. A general preference for accessing treatment was observed for online (OR 1·21, 95% CI 1·15–1·28) versus traditional general practice (1·18, 1·12–1·24), pharmacy (1·15, 1·10–1·22), or clinic (OR 1) services. Little difference was observed between face-to-face, telephone, instant messaging or email methods of access. No significant difference in preferences was seen for antibiotic provision (eg, collection from pharmacy vs postal delivery).InterpretationDCE coefficients can help estimate uptake probabilities for redesigned chlamydia pathways. Although this DCE was conducted in an online population, which might limit generalisabiity to other populations, findings could assist technology developers, policy makers, commissioners, and service providers to optimise the adoption of emerging technologies and service redesign.FundingThe doctoral fellowship of SE is supported by the Medical Research Council under the UK Clinical Research Collaboration Translational Infection Research Initiative (grant G0901608).     

Chlamydia trachomatis in human immunodeficiency virus-infected men treated at a referral hospital for sexually transmitted diseases in the Amazonas,Brazil

ObjectivesThe aim of the present study was to determine the Chlamydia trachomatis prevalence and to identify the demographic, behavioural and clinical factors associated with C. trachomatis in human immunodeficiency virus infected men.StudyThis was a cross-sectional study of C. trachomatis prevalence among human immunodeficiency virus-infected men enrolled at the Outpatient clinic of acquired immunodeficiency syndrome of the Fundação de Medicina Tropical Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil. C. trachomatis deoxyribonucleic acid from urethral samples was purified and submitted to real time polymerase chain reaction to identify the presence of C. trachomatis.ResultsA total of 276 human immunodeficiency virus-infected men were included in the study. The prevalence of C. trachomatis infection was 12% (95% confidence interval 8.1%–15.7%). The mean age of the participants was 34.63 (standard deviation 10.80) years. Of the 276 human immunodeficiency virus-infected men, 93 (56.2%) had more than one sexual partner in the past year and 105 (38.0%) reported having their first sexual intercourse under the age of 15 years. Men having sex with men and bisexuals amounted to 61.2% of the studied population. A total of 71.7% had received human immunodeficiency virus diagnosis in the last three years and 55.1% were using antiretroviral therapy. Factors associated with C. trachomatis infection in the logistic model were being single (p < 0.034), men having sex with men (p < 0.021), and having previous sexually transmitted diseases (p < 0.001).ConclusionThe high prevalence of C. trachomatis infection among human immunodeficiency virus-infected men highlights that screening human immunodeficiency virus-infected men for C. trachomatis, especially among men having sex with men, is paramount to control the spread of C. trachomatis infection.     

Characterising the alcohol harm paradox: a population-based survey of adults in England

BackgroundThe alcohol harm paradox refers to the positive association of socioeconomic status (SES) with alcohol consumption and negative association with alcohol-related harm and dependence. To inform future research and to help elucidate the cause of the alcohol harm paradox, this study aimed to assess how far the paradox extends to a range of measures of SES and whether it varies by demographic characteristics.MethodsBetween March and December, 2014, data were collected on 16 871 participants from the Alcohol Toolkit Study, a monthly population survey of adults aged 16 and older. In this survey, interviews with 1800 individuals in England are conducted each month by the market research company, Ipsos MORI. Participants were asked to complete the Alcohol Use Disorders Identification Test (AUDIT), which consists of three parts: alcohol consumption (AUDIT-C), alcohol dependence (AUDIT-dependence), and alcohol harm (AUDIT-harm). SES was categorised as follows: qualifications after the age of 16 years (yes, no), employed full time (yes, no), owns own house (yes, no), owns own car (yes, no), income of less than £11 499 (yes, no), and a classification based on occupation called social grade (AB, C1, C2, D, E). A composite score was also derived with multiple correspondence analysis. Prevalence data were weighted to match the population in England.Findings11 295 participants (71%) reported that they drank alcohol (95% CI 69·7–71·2). Those who were aged 35–44 years (p=0·0009), 45–54 (p<0·0001), 55–64 (p<0·0001) and 65 years or over (p=0·0107) had higher odds of reporting that they drank alcohol than those aged 16–24. Those of higher socioeconomic status (p<0·0001) and men (p<0·0001), also had higher odds of drinking alcohol. After adjustment, positive associations with AUDIT-C were found between social grade AB relative to C2 (β=–0·26, p=0·0067) and D (β=–0·54, p<0·0001), educational level (β=–0·19, p=0·0242), and the composite score (β=–0·12, p<0·0001). All SES measures, except for car ownership and educational qualifications, were negatively associated with AUDIT-harm and AUDIT-dependence scores. The alcohol harm paradox was moderated by demographic characteristics: AUDIT-dependence was associated with measures of SES in men (β=–0·07, p=0·0110) but not women; and associations between AUDIT-C and SES were strengthened with increasing age, whereas associations between AUDIT-dependence and SES diminished.InterpretationAmong adults in England, the alcohol harm paradox is apparent across a range of measures of SES and seems to be more evident in younger men than in other demographic groups.FundingEB's salary is funded by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR) and Cancer Research UK (CRUK). JB is funded by CRUK and the Society for the Study of Addiction. RW is funded by CRUK. The Alcohol Toolkit Study is funded by the NIHR SPHR.     

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).     

Maternal depression in the 5 years after childbirth among women with and without perinatal depression: a population-based cohort study

BackgroundMany studies estimate the burden of perinatal depression, yet few have assessed continuing patterns of maternal depression in the initial years after childbirth. Since numerous child outcomes are related to perinatal depression, understanding ongoing childhood exposure has potentially important implications for families and clinical practice. We aimed to describe episodes of maternal depression during the first 5 years of children's lives in relation to the presence of maternal antenatal depression, postnatal depression, or both.MethodsWe used a population-based cohort of mother–child pairs from England who had linked primary care and hospital admission data from, respectively, the Clinical Practice Research Datalink and Hospital Episode Statistics for 1997–2014. Incidence of maternal depression was estimated per 100 person-years from 6 months after childbirth to the child's fifth birthday, stratified by whether the mother had antenatal depression, postnatal depression, or both. Incidence rate ratios (IRRs), adjusting for maternal age at delivery, socioeconomic status, and number of children aged 0–4 years in the household, were estimated with Poisson regression. Clinical diagnoses, antidepressant treatment, and admissions to hospital were used to identify episodes of depression. The study was approved by the Independent Scientific Advisory Committee for the Medicines and Healthcare products Regulatory Agency in February, 2014.FindingsOf the 209 418 mothers in the cohort, 5091 (2·4%) had antenatal depression, 13 526 (6·5%) postnatal depression, and 6663 (3·2%) both. Incidence rates of maternal depression when the child was aged 6 months to 4 years were 22·5/100 person-years (95% CI 21·7–23·3) after antenatal depression, 16·0 (15·6–16·4) after postnatal depression, and 14·5 (14·0–15·1) after both, compared with 6·4 (6·3–6·5) for women without perinatal depression. After adjustment, depression rates remained more than twice as high among women with perinatal depression as those without (adjusted IRR 3·28 [3·16–3·39] after antenatal depression, 2·32 [2·26–2·39] after postnatal depression, and 2·18 [2·08–2·27] after both).InterpretationWomen with perinatal depression have an increased risk of subsequent depressive episodes during the first 5 years of their child's life. Studies assessing perinatal depression as a risk factor for child outcomes need also to consider the effect of recurrent maternal depressive episodes occurring in the child's early years. This study only captured depressive episodes where medical attention was sought, and was unable to assess the effect of marital status and social support on risk of depression.FundingRB is funded by the National Institute for Health Research (NIHR) School for Primary Care Research and the University of Nottingham.     

Does exposure to opioid substitution treatment at prison release reduce the risk of death? A prospective,observational study in England

BackgroundOpioid use disorders are common in the prison population. Prisoners face an acute risk of death in the first 4 weeks after release. We tested whether prison-based opioid substitution treatment (OST) reduces post-release mortality.MethodsThis was a national prospective cohort study of adult prisoners with opioid use disorders recruited from 39 prisons (and transferred to and released from 123 prisons) in England during 2010–16 linked to Prison Health, Justice Statistics Analytical Services, Office for National Statistics, and National Drug Treatment Monitoring System. We assessed the association between OST exposure at prison release and all-cause mortality using Cox proportional hazards models adjusted for demographic and behavioural confounders and community treatment.FindingsWe created a risk set of 15 141 incarcerations (12 260 individuals) with opioid use disorders (8645 exposed to OST on release, 6496 unexposed). 401 individuals died during the observation period (160 in the first year, 24 in the first month). The mortality risk in the OST-exposed group was lower than in the unexposed group in the first 4 weeks (0·93 per 100 person-years [95% CI 0·4–2·1] vs 3·67 [2·3–5·8]; unadjusted hazard ratio [HR] 0·25, 95% CI 0·10–0·64). Mortality risk did not differ from 4 weeks to 4 months (HR 1·07, 95% CI 0·57–2·00) or from 4 months to 1 year (0·97, 0·65–1·45). OST-exposed prisoners were more likely than the non-exposed group to enter community treatment (odds ratio 2·47, 95% CI 2·3–2·65). The protective effect of OST exposure was not attenuated after adjustment for demographic or behavioural confounders or for community drug treatment (adjusted HR 0·27, 95% CI 0·11–0·71). There was no evidence of an interaction between OST exposure on prison release and community treatment (ratio of HRs 0·99, 95% CI 0·12–8·11; p for likelihood ratio test=0·99).InterpretationOST at prison release lowered risk of mortality in the first month by 75% (removing the excess risk of death in people with an opioid use disorder leaving prison compared with risk of death in the community after 4 weeks) and increased the likelihood of entering drug treatment in the community.FundingDepartment of Health, NHS England, Public Health England.     

Time trends in hospital admissions for violent,self-inflicted,and drug-related or alcohol-related injury for adolescents in England and Scotland, 2005–11: observational population-based study

BackgroundIn England, a third of emergency admissions of adolescents for injury are adversity related (violent, self-inflicted, drug-related, or alcohol-related). A comparison of time trends of the incidence of admissions for violent injury between England and Scotland revealed steeper declines in 2005–11 in Scotland. We aimed to determine whether incidence of admissions for any adversity-related injury varied substantially between the two countries.MethodsWe conducted time-series analyses of emergency admissions between 2005 and 2011 for adversity-related injury (defined by the 10th revision of the International Classification of Diseases) to National Health Service hospitals in England (Hospital Episode Statistics) and in Scotland (Scottish Morbidity Records) in 10–18 year olds. Analyses were stratified in groups by sex and age (10–12 years, 13–15, 16–18) and were adjusted for background trends in admissions for any injury.FindingsIn 2005, rates of admissions per 100 000 for adversity-related injury ranged from 48·9 for girls aged 10–12 years in Scotland (95% CI 0–98·9) to 978·2 for boys aged 16–18 years in Scotland (764·0–1184·3). Rates for 10–12-year-old girls and boys, respectively, were similar between the two countries, but were higher in Scotland for 13–15 year olds and 16–18 year olds. From 2005 to 2011, rates decreased in both countries for all groups by −1·5% per year (95% CI −3·2 to 0·21) to −10·0% per year (–15·2 to −4·4), except for 16–18-year-old girls and boys in England, where rates increased by 0·25% per year (0·09–0·41) to 2·5% per year (1·2–3·7). Decreases in all groups were greater in Scotland than in England after adjustment for trends in admissions for any injury. By 2011, although incidences of admissions for adversity-related injury in adolescents aged 13–15 and 16–18 years remained higher in Scotland, differences between England and Scotland were smaller than in 2005.InterpretationOur finding that rates of admissions for adversity-related injury decreased more steeply in Scotland than in England raises questions about the factors driving these discrepancies. Several initiatives within each country might have been influential. For example, the English government attempted to tackle incidence of violence and gangs by targeting high crime areas with higher levels of policing. The Scottish government set up contracts with local gangs to exchange a so-called clean slate for psychosocial support. Further research into potentially successful practices in Scotland could be used to develop future initiatives to reduce harm in adolescents in both countries and further afield. More research is needed, especially into why the incidence of admissions for adversity-related injury increased for older adolescents in England.FundingAH was supported by the Policy Research Unit in the Health of Children, Young People and Families, which is funded by the Department of Health Policy Research Programme (grant reference number 109/0001). AH is also supported by the University College London Impact studentship. The study sponsors played no part in the design, data analysis, and interpretation of this study; the writing of the abstract; or the decision to submit the abstract for publication.     

Effects on alcohol consumption of announcing revised UK low-risk drinking guidelines: findings from a monthly cross-sectional survey

BackgroundHealth authorities publish alcohol consumption guidelines for low-risk drinking in most high-income countries but the effects of these guidelines on alcohol consumption are unclear. In January, 2016, the UK's Chief Medical Officers announced revised guidelines recommending that men and women should not regularly drink more than 14 units per week, a reduction to the previous guideline for men of 3–4 units per day. We aimed to evaluate the effect of announcing the revised guidelines on alcohol consumption.MethodsData were collected from March, 2014, to October, 2017, using the Alcohol Toolkit Survey, a monthly repeat cross-sectional survey of approximately 1800 adults (older than 16 years) resident in England. The survey uses a hybrid between random location sampling and quota sampling designed to generate a nationally representative sample, which selects random areas in England (about 300 households) from strata defined by area-level geographical and sociodemographic profiles. Participants provided verbal informed consent. The University College London ethics committee granted ethical approval for the Alcohol Toolkit Study and The University of Sheffield for the evaluation of the UK lower-risk drinking guidelines. The primary outcome is participants’ Alcohol Use Disorders Identification Test for Consumption (AUDIT-C) scores. Effects were estimated using segmented regression. Secondary analyses test for alternative breakpoints in the long-term trend and pulse effects. All analyses were preregistered in the ISRCTN registry, number ISRCTN15189062.FindingsAt baseline, 70·4% of the sample were drinkers and the mean AUDIT-C score was 2·8. The main analysis showed no significant step-change in AUDIT-C scores immediately following announcement of the guideline (β=0·001 [95% CI –0·079 to 0·099]; p=0·82) and the trend changed significantly such that scores increased by 0·005 each month (β=0·008 [0·001–0·015]; p=0·015). This finding was not robust as secondary analyses of alternative breakpoints suggested the change in behaviour began in June, before the new guidelines were announced. Secondary analyses also suggest that AUDIT-C scores reduced temporarily for 3 months (a pulse effect) after the announcement (β=–0·126 [–0·218 to –0·034]; p=0·007).InterpretationAnnouncing new UK drinking guidelines with no large-scale organised promotion did not lead to a substantial or sustained reduction in drinking or a downturn in long-term alcohol consumption behaviour. Well designed promotional campaigns might improve the effect of drinking guidelines on alcohol consumption. This study is limited by potential seasonal confounding—January is typically a light-drinking month, whereas December is a heavy-drinking month. We control for seasonal trends but this approach might be inadequate if seasonality varies substantially between years as our time series is relatively short.FundingNational Institute for Health Research Public Health Research Programme, School for Public Health Research, Cancer Research UK.     

Effect of the NHS Health Check programme on cardiovascular disease risk factors during 6 years' follow-up: matched cohort study

Background

The National Health Service (NHS) Health Check (NHSHC) is a primary prevention programme aimed at reducing the risk of cardiovascular diseases. We evaluated the effect of this programme up to 6 years after its implementation on risk factors and provision of risk management interventions.

Treatment outcomes in individuals diagnosed with chlamydia in SH:24, an online sexual health service: a retrospective audit

Background

SH:24 is the UK's only fully integrated online sexual health service, developed between public health and National Health Service specialist services and providing testing for sexually transmitted infections, online chlamydia treatment, clinical support, and contraception. Users self-sample for chlamydia and gonorrhoea using a vulvovaginal swab (female users) or a urine sample (male), with or without pharyngeal or rectal swabs. At the time of audit SH:24 provided chlamydia home treatment in 66% SH:24 areas; 90% of users in these areas choose this option. 75% of users diagnosed with chlamydia receive home treatment; 25% are ineligible because of patient choice, unavailability of online treatment, or complex infection. We aimed to evaluate treatment outcomes in SH:24 users diagnosed with chlamydia.

Not that different or just not measurable? The contribution of health care to changes in population health outcomes in the UK before and after devolution

BackgroundThe extent to which health care makes a difference to population health outcomes continues to be debated among researchers and practitioners alike. The National Health Service (NHS) in the UK provides an important natural experiment to study this association. In this study we aimed to quantify it using mortality from causes considered amenable to health care (amenable mortality), assessing trends before and after political devolution in 2000 in the four countries of the UK.MethodsWe assessed pre-devolution (1990–2000) and post-devolution (2000–12) trends in age-standardised death rates from amenable mortality among those aged 0–64 years, 65–74, and 0–74. We estimated absolute change over 1990–2012 by fitting a linear regression and relative change as the average annual percentage change. We fitted a Poisson regression model to estimate relative risk (RR) of amenable death rates between given timepoints.FindingsBetween 1990 and 2012, amenable mortality per 100 000 was highest in Scotland and lowest in England for both men and women; death rates fell in all countries, and the change accelerated after devolution. During 1990–2000, the greatest decline was seen in Northern Ireland (men RR 0·66, 95% CI 0·53–0·81; women 0·66, 0·53–0·81), and the lowest was seen in Wales (0·70, 0·56–0·87 and 0·74, 0·57–0·95, respectively). Similar patterns were seen during 2000–12, although the declines were larger than those for 1990–2000 in all four countries among both men and women, ranging from 0·50 (0·38–0·67) in Northern Ireland to 0·56 (0·43–0·74) in Wales (women in Northern Ireland 0·50, 0·36–0·69 and Scotland 0·65, 0·48–0·87). As a result of these mortality trends, differences in levels of amenable mortality between England and the other three countries narrowed between 1990 and 2012.InterpretationThis study suggests that different NHS policies associated with political devolution has had little measurable effect on population health outcomes as measured by amenable mortality. An acceleration of the decline in amenable mortality since 2000 in all four countries might be indicative of an increase in the availability of resources for health care in each system.FundingPart funded by the Nuffield Trust and the Health Foundation.     

Minimum spread of the new Swedish variant of Chlamydia trachomatis and distribution of C. trachomatis ompA genotypes in three geographically distant areas of Spain, 2011–2012

Purpose

The aim of this study was to determine the presence of the new Swedish Chlamydia trachomatis (C. trachomatis) variant (nvCT) and the distribution of C. trachomatis ompA genotypes in three geographically distant regions of Spain.

Methods

The genotypes of strains causing 624 episodes of infection (January 2011–September 2012) were studied using a nested PCR that amplifies a fragment of the ompA gene, followed by sequencing. To detect nvCT, a real-time PCR was used that amplifies a fragment of the cryptic plasmid with a 377 base pair deletion, which identifies the nvCT.

Results and conclusion

The ompA genotype was identified in 565 (90.5 %) episodes. Eleven genotypes were detected, of which nine were found in all three regions. Only one nvCT strain was detected (0.4 %), despite the predominance of genotype E (41 %). Other frequent genotypes were genotypes D (19 %), F (13 %), G (11 %), and J (7 %). Genotype L2b, causing lymphogranuloma venereum, was detected in men who have sex with men (MSM) in all three regions. Genotypes E and F were more frequent in women and heterosexual men, and genotypes D, G, J and L2b in MSM. In men, the main factor causing differences in the distribution of C. trachomatis was sexual behavior (MSM versus heterosexual men), while the distribution of C. trachomatis genotypes was similar in women and heterosexual men.     

Maternal and paternal obesity and adverse pregnancy outcomes in China: a cohort study

Background

There is growing concern about the potential effect of parental obesity on the newborn child's birth outcomes and health. However, few studies have examined whether parental obesity before pregnancy affects the risk of adverse pregnancy outcomes. We aimed to systematically evaluate the associations of adverse pregnancy outcomes with prepregnancy body-mass index (BMI) of the mother and the father.