Mainstreaming gambling-related harm in Britain as a public health issue

Aim

In this paper we make the case for gambling–related harm treatment services in Britain to be mainstreamed within the remit of public health. Although the focus of this article is on the British situation many of these issues are generalisable to other jurisdictions.

The profile of problem gamblers

In Britain, 0.9 % of adults are problem gamblers, and it is more common in the young, socially deprived and the ethnic minorities.

Who provides and who should provide treatment services?

At present in Britain, almost all dedicated funding to address gambling-related harm is provided by voluntary contributions from the gambling industry and the level of service provision is far from adequate.

Mainstreaming gambling treatment

Problem gambling is associated with a range of health and social harms yet it often goes unnoticed for a variety of reasons. Early interventions can minimise or prevent the negative effects of problem gambling on various spheres of the gambler’s life, his/her family and wider society.

Conclusion

Consistent with plans to move the commissioning of drug-misuse treatment services within the remit of public health, it would seem entirely logical to commission gambling-related harm treatment services from the public health ‘purse’, and to request that gambling-related harm falls under the remit of the new Health and Well-Being Boards.     

The acceptability and feasibility of peer worker support role in community based HCV treatment for injecting drug users

Background

The Mexico-U.S. border region is experiencing rising rates of blood-borne infections among injection drug users (IDUs), emphasizing the need for harm reduction interventions.

Methods

We assessed the religious and cultural factors affecting the acceptability and feasibility of three harm reduction interventions – Needle exchange programs (NEPs), syringe vending machines, and safer injection facilities (SIFs) – in Tijuana, Mexico. In-depth qualitative interviews were conducted with 40 community stakeholders to explore cultural and societal-related themes.

Results

Themes that emerged included Tijuana's location as a border city, family values, and culture as a mediator of social stigma and empathy towards IDUs. Perception of low levels of both awareness and socio-cultural readiness for harm reduction interventions was noted. Religious culture emerged as a theme, highlighting the important role religious leaders play in determining community responses to harm reduction and rehabilitation strategies for IDUs. The influence of religious culture on stakeholders' opinions concerning harm reduction interventions was evidenced by discussions of family and social values, stigma, and resulting policies.

Conclusion

Religion and politics were described as both a perceived benefit and deterrent, highlighting the need to further explore the overall influences of culture on the acceptability and implementation of harm reduction programs for drug users.     

Perceptions of cannabis as a stigmatized medicine: a qualitative descriptive study

Background

Despite its increasing prevalence and acceptance among the general public, cannabis use continues to be viewed as an aberrant activity in many contexts. However, little is known about how stigma associated with cannabis use affects individuals who use cannabis for therapeutic purposes (CTP) and what strategies these individuals employ to manage associated stigma. The aim of this Canadian study was to describe users’ perceptions of and responses to the stigma attached to using CTP.

Methods

Twenty-three individuals who were using CTP for a range of health problems took part in semi-structured interviews. Transcribed data were analyzed using an inductive approach and comparative strategies to explore participants’ perceptions of CTP and identify themes.

Results

Participant experiences of stigma were related to negative views of cannabis as a recreational drug, the current criminal sanctions associated with cannabis use, and using cannabis in the context of stigmatizing vulnerability (related to existing illness and disability). Strategies for managing the resulting stigma of using CTP included: keeping CTP ‘undercover’; educating those who did not approve of or understand CTP use; and using cannabis responsibly.

Conclusions

Understanding how individuals perceive and respond to stigma can inform the development of strategies aimed at reducing stigma associated with the use of CTP and thereby address barriers faced by those using this medicine.     

Problematic mobile phone use in adolescence: a cross-sectional study

Aim

In recent years, mobile phone use has become increasingly common among Italian youth, while a growing scientific literature has been identifying the occurrence of a problematic mobile phone use which seems to share some features of other conditions often referred to as behavioural addictions. The study aimed to assess the prevalence of problematic mobile phone use in a population of Italian adolescents and its association with other behavioural addictions.

Subjects and methods

The Mobile Addiction Test (MAT) was administered to 2,790 high school students from Barletta, an Italian town, together with the South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA), the Compulsive Buying Scale (CBS), the Internet Addiction Test (IAT), the Exercise Addiction Inventory (EAI), the Work Addiction Risk Test (WART).

Results

MAT scores fitted a Gaussian distribution model. Scores????17 was found as a cut-off value over which identifying problematic mobile phone users. Overall prevalence of problematic mobile phone use was 6.3%; this condition was associated with other behavioural addictions like compulsive buying.

Conclusion

Problematic mobile phone use in adolescence should become a public health issue, and it could be a cause of health problems and social costs.     

“I can’t do this,it’s too much”: building social inclusion in cancer diagnosis and treatment experiences of Aboriginal people,their carers and health workers

Objectives

Social inclusion theory has been used to understand how people at the margins of society engage with service provision. The aim of this paper was to explore the cancer care experiences of Aboriginal people in NSW using a social inclusion lens.

Methods

Qualitative interviews were conducted with 22 Aboriginal people with cancer, 18 carers of Aboriginal people and 16 health care workers.

Results

Participants’ narratives described experiences that could be considered to be situational factors in social inclusion such as difficulties in managing the practical and logistic aspects of accessing cancer care. Three factors were identified as processes of social inclusion that tied these experiences together including socio-economic security, trust (or mistrust arising from historic and current experience of discrimination), and difficulties in knowing the system of cancer treatment.

Conclusions

These three factors may act as barriers to the social inclusion of Aboriginal people in cancer treatment. This challenges the cancer care system to work to acknowledge these forces and create practical and symbolic responses, in partnership with Aboriginal people, communities and health organisations.     

Longitudinal study on health-related quality of life among child and adolescent survivors of the 2008 Sichuan earthquake

Purpose

To longitudinally characterize child survivors’ quality of life after a massive earthquake in low- and middle-income settings.

Methods

Population-based surveys were conducted in the severely affected areas 15 and 36 months after the earthquake, using a multi-stage systematic sampling design.

Results

A total of 596 participants were included in the initial assessment, of which 430 were re-surveyed in the follow-up assessment. For both assessments, means of the PedsQL total and subscale scores fell significantly below the general healthy children (P < 0.05 for all comparisons). Reduction in PedsQL total scores was observed from the initial to the follow-up assessment (82.2 vs. 80.3, P = 0.01). In regression analysis, mental health symptoms were examined as the biggest contributors for PedsQL scores, and girls and older children were found to report lower PedsQL scores than their counterparts.

Conclusions

Health-related quality of life among child and adolescent survivors decreased over time. Besides helping children with identified risk experiences, attention should also be allocated to children without specific traumatic experiences, since the earthquake may have a delayed effect on them.     

A cross-sectional study of public attitudes towards safer drug use practices in British Columbia,Canada

Background

Harm reduction programs are often vulnerable to political and vocal opposition despite documented evidence of their effectiveness and economic benefit. It is not well understood if opponents to harm reduction represent the general public’s attitudes.

Objective

To understand the attitudes of the people of British Columbia (BC) towards various harm reduction strategies and services, and factors associated with support for harm reduction.

Methods

A random-digit dialing telephone survey assessing attitudes towards various harm reduction strategies was administered to British Columbians in August 2011 (n?=?2000). We compared the level of support for general harm reduction by sex, age, education level, and area of residence (Health Authority region) (χ²). Multivariate logistic regression was used to assess odds of support for harm reduction.

Results

Overall support for general harm reduction among participants was 76%; needle distribution 72%; needle distribution in one’s local community 65%; and safer inhalation equipment distribution 52%. In the multivariate analysis, those with significantly lower odds of supporting harm reduction were male, older, had equal or less than high school education or completed a certificate/diploma program, and resided in the Fraser Health Authority region. The Health Authority region with a municipality that has introduced a bylaw prohibiting the implementation of harm reduction services was found to have 69% support for harm reduction. Another Health Authority region with a municipality that closed a long-standing needle distribution site was found to have over 78% support.

Conclusion

In contrast to some local policies, our results show the British Columbians surveyed in our study support harm reduction. It is unclear whether policy makers are swayed by a vocal minority or block harm reduction activities for other reasons. Tailoring messages towards segments of the public less likely to support harm reduction, as well civic policy-makers and the media, may help to reduce stigma and gain support for harm reduction services designed to protect and improve the health of the individual and the public.

     

School Reintegration Following Psychiatric Hospitalization: An Ecological Perspective

Background

School reintegration following psychiatric hospitalization can be challenging for children, their families, and school personnel. While school reintegration of children with physical illness has received considerable professional attention, our knowledge about the needs of children returning to school after psychiatric hospitalization is still limited.

Objective

This paper delineates an ecological perspective on school reintegration of children after hospitalization for mental health reasons. This perspective takes into account the multiple social systems in which children are embedded and focuses on both individual and environmental factors that may contribute to a child’s well-being or, conversely, trigger emotional and behavioral difficulties.

Methods

This is a theoretical paper based on the systematic review of empirical literature related to psychiatric hospitalization of children, post discharge adjustment, school reintegration following hospitalization, mental health stigma in children, and cross-agency collaboration.

Results

Several ecological factors that may affect school reintegration after psychiatric hospitalization were identified, including: (1) child/youth experiences with and perceptions of having a mental health condition, being hospitalized, and subsequent school reentry; (2) parental experiences and perceptions of child/youth psychiatric condition and hospitalization; (3) attitudes and reactions from members of the child/youth school ecology including teachers and peers; and (4) inter-disciplinary collaboration. The paper proposes ecologically informed guidelines to facilitate successful school reintegration and discusses the roles of the school-based mental health professionals in this process.

Conclusions

While complex and challenging, a successful reintegration may be the key step in reducing inpatient recidivism rates and improving a child’s future academic and behavioral success.     

Predictors of HIV infection and prevalence for syphilis infection among injection drug users in China: Community-based surveys along major drug trafficking routes

Background

Despite France being regarded as a model of efficient harm reduction policy and equity of access to care in the general community, the health of French inmates is a critical issue, as harm reduction measures are either inaccessible or only partially implemented in French prisons.

Method

Using specific inclusion and exclusion criteria, information was collected and analyzed about HIV, HBV and HCV prevalence, risk practices, mortality, access to harm reduction measures and care for French prison inmates.

Results

Data about the occurrence of bloodborne diseases, drug use and access to care in prisons remain limited and need urgent updating. Needle exchange programs are not yet available in French prisons and harm reduction interventions and access to OST remain limited or are heterogeneous across prisons. The continuity of care at prison entry and after release remains problematic and should be among the primary public health priorities for French prisoners.

Conclusion

Preventive and harm reduction measures should be urgently introduced at least as pilot programs. The implementation of such measures, not yet available in French prisons, is not only a human right for prison inmates but can also provide important public health benefits for the general population.     

Use of fake identification to purchase alcohol amongst 15-16 year olds: a cross-sectional survey examining alcohol access,consumption and harm

Objectives

Injection drug users (IDUs) are at high risk for HIV, hepatitis, overdose and other harms. Greater drug treatment availability has been shown to reduce these harms among IDUs. Yet, little is known about changes in drug treatment availability for IDUs in the U.S. This paper investigates change in drug treatment coverage for IDUs in 90 metropolitan statistical areas (MSAs) during 1993-2002.

Methods

We define treatment coverage as the percent of IDUs who are in treatment. The number of IDUs in drug treatment is calculated from treatment entry data and treatment census data acquired from the Substance Abuse and Mental Health Service Administration, divided by our estimated number of IDUs in each MSA.

Results

Treatment coverage was low in 1993 (mean 6.7%; median 6.0%) and only increased to a mean of 8.3% and median of 8.0% coverage in 2002.

Conclusions

Although some MSAs experienced increases in treatment coverage over time, overall levels of coverage were low. The persistence of low drug treatment coverage for IDUs represents a failure by the U.S. health care system to prevent avoidable harms and unnecessary deaths in this population. Policy makers should expand drug treatment for IDUs to reduce blood-borne infections and community harms associated with untreated injection drug use.     

Perceived Harmfulness of Substance Use: A Pilot Study

Background:

Harm ratings of substances help in understanding the perception toward substance use and formulating policies. Evidence of such harm ratings by substance users and their caregivers provides a clearer perspective of those who experience and observe such harm closely.

Materials and Methods:

Substance users and their caregivers were recruited from the Drug De-addiction and Treatment Centre of PGIMER, Chandigarh. Sociodemographic details of the subjects were noted. The subjects were then asked to rate a list of psychoactive preparations according to the harms they thought the preparation caused. The list of substances was developed taking into consideration substance commonly encountered in the geographical area. The harm ratings were transformed on a scale of 0-100.

Results:

All subjects were males and majority of them were educated above 10^th standard, were not employed and belonged to urban background. Most of them had taken psychoactive substances in their lifetimes but were currently abstinent. Most of the subjects endorsed intravenous drugs as the most harmful, followed by heroin. Beer and chewable tobacco considered the least harmful substances. Greater degree of education was associated with lower harm rankings for heroin, cannabis, dextropropoxyphene, and raw opium; while urban residence was associated with greater harm ratings for cannabis and raw opium. Differences in the harms were perceived for different preparations of the same active compound for alcohol and nicotine.

Conclusion:

Harm ratings of substances can be a useful guide while formulating policies and allocating resources. Need for further research extending this pilot study is emphasized.     

Gender, educational and age differences in meanings that underlie global self-rated health

Objectives

The single-item question on self-rated health has been widely used in surveys. This study aims to explore which frames of reference are used by respondents when answering this question, to describe differences in the used frame of reference according to gender, educational background and age, and to determine whether subgroup differences can be explained by differences in prior health experiences.

Methods

Face-to-face interviews were conducted in a sample of 310 adults who were asked to rate their health using a single-item question with closed-ended answering categories and to explain the reasons for the rating they gave with open-ended probes. Different indicators of prior health experiences were taken into account.

Results

Physical health problems were the most utilized referents. However, participants also mentioned reasons that go beyond the physical dimension of health. Subgroup differences were found. Prior health experiences partly explained subgroup differences for some referents, but not for others.

Conclusions

Investigators using the single question on self-rated health for comparing health across different population groups should be aware that the meaning of the question varies across different socio-demographic groups.     

Barriers to retention in methadone maintenance therapy among people who inject drugs in Bangkok,Thailand: a mixed-methods study

Background

Methadone maintenance therapy (MMT) is a mainstay for treating opioid use disorder and preventing and managing HIV among people who inject drugs (PWID). While previous research suggested low dosing of methadone and high rates of discontinuation of MMT among PWID in Thailand, little is known about patients’ lived experiences with MMT in this setting. Therefore, we conducted a mixed-methods study to examine barriers to retention in MMT among PWID in Bangkok, Thailand, with particular attention to methadone dosing.

Methods

Bivariate statistics were used to analyze quantitative survey data collected from methadone-treated PWID between July and October 2011. Qualitative data collected through semi-structured interviews with 16 methadone-treated PWID between July 2011 and June 2012 were analyzed thematically, with a focus on individual-level, social-structural, and environmental barriers to accessing MMT.

Results

Among 158 survey participants, a median dosage of methadone was 30 mg/day (interquartile range 20–50). Of these, 15.8% reported having acquired street methadone due to low prescribed dosages of methadone and 19.0% reported recent syringe sharing. Qualitative interview data indicated some methadone provider-related barriers, including discouraging patients from using methadone due to it being a Western medicine, difficulty negotiating higher doses of methadone, and abrupt dose reductions without patient consultation (involving the provision of non-medicated “syrup” in some cases). Social-structural and environmental barriers to optimal MMT access included intense police surveillance of methadone clinics; and frequent incarceration of PWID and a lack of access to methadone in prisons.

Conclusions

Among our sample of methadone-treated PWID, methadone dosages were suboptimal according to the international guidelines. Poor adherence to international guidelines for opioid agonist therapies, aggressive law enforcement, and a lack of methadone in prisons need to be addressed to optimize MMT and reduce harms associated with untreated opioid use disorder in Thailand.

     

A scoping review of unintended harm associated with public health interventions: towards a typology and an understanding of underlying factors

Objectives

Unintended harm theory as related to public health interventions (PHI) is under developed, with harm evaluation and reporting often absent or incomplete. This review presents a typology for, and underlying factors linked to, PHI-associated unintended harm.

Methods

This scoping review was conducted electronically and includes articles from 1992 to June of 2013. Out of 2,490 originally identified titles, 26 full-text articles were included that discussed unintended harm associated with PHI. An iterative data analysis process was utilized to identify both a typology and underlying factors associated with unintended harm.

Results

A typology of PHI-associated unintended harm was identified: (1) physical; (2) psychosocial; (3) economic; (4) cultural and (5) environmental. Five underlying factors associated with PHI unintended harm emerged: (1) limited and/or poor quality evidence; (2) prevention of one extreme leads to another (boomerang effects); (3) lack of community engagement; (4) ignoring root causes; and (5) higher-income country PHI implementation in a lower- or middle-income country.

Conclusions

PHI planning and evaluation frameworks may benefit from the consideration and potential incorporation of the unintended harm typology and underlying factors.     

Enacted and internalized stigma and quality of life among people with HIV: the role of group identity

Purpose

This study analyzes the mediating role of social identity in the relationship between enacted stigma and internalized stigma and quality of life of people with HIV.

Methods

A total of 557 people with HIV participated in this study. Participants were recruited from hospitals and non-governmental organizations. Questionnaires measuring perceived stigma (Berger’s HIV Stigma Scale), social identity (Cameron’s three factor identity scale), and quality of life (Ruiz and Baca’s Quality of Life Questionnaire) were administered. The instruments were adapted for use with the Spanish population. Structural equation modeling (SEM) was used to test the mediation model, and multigroup SEM was conducted to evaluate its invariance.

Results

Both enacted stigma and internalized stigma had a negative influence on the quality of life of people with HIV, but this influence occurred in different ways. Enacted stigma had a direct negative influence on quality of life. No dimension of group identity protected people with HIV from its negative influence. However, the negative influence of internalized stigma was totally mediated by some dimensions of group identification, mainly through in-group affect.

Conclusions

Group identification not only did not protect people with HIV from the negative effects of stigmatization, but it may even be detrimental in the case of internalized stigma. This suggests that in highly stigmatized groups, the salience of identity is negative and worsens the members’ opinion of their own group. This argues for different kinds of intervention to improve the quality of life of people with HIV.     

Harm reduction and law enforcement in Vietnam: influences on street policing

Background and rationale

The HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for IDUs, required to participate in drug control practices (especially meeting quotas for detention centres) which impede support for harm reduction. We studied influences on ward level police regarding harm reduction in Hanoi to learn how to better target education and structural change.

Methods

After document review, we interviewed informants from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. Topics covered included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police.

Results

Police perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention. Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street.

Discussion

Ward police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police.     

IGeL oder Nicht-IGeL

Background

Cancer screening tests such as ultrasound scans, extensive skin cancer screening, or the prostate-specific antigen (PSA) test are among the most commonly used individual out-of-pocket health services (in German: Individuelle Gesundheitsleistungen, or IGeL) among people who have statutory health insurance in Germany. They are usually offered as an add-on to the services that are covered by statutory insurers.

Questions and methods

There are a number of reasons why cancer screening tests might not be covered by insurers. The main reasons are because the test does not have any clear benefits, and because the harms outweigh the benefits. This article describes the fundamental difficulties of, and the requirements imposed on, benefit assessments of cancer screening tests.

Results

Cancer screening tests that are available as individual out-of-pocket health services are always potentially harmful, while their benefit is either not clear or contested, or there is clearly no benefit.

Discussion

Health-care providers who offer cancer screening tests are required to provide interested people with relevant information on the related benefits, harms, and uncertainties of the tests, so as to enable an informed decision. This is especially important when it comes to “IGeL” services.