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Aims: To test the effectiveness of a theoretically based text‐message intervention to reduce binge drinking among socially disadvantaged men. Design: A multi‐centre parallel group, pragmatic, individually randomized controlled trial. Setting: Community‐based study conducted in four regions of Scotland. Participants: A total of 825 men aged 25–44 years recruited from socially disadvantaged areas who had two or more episodes of binge drinking (> 8 UK units on a single occasion) in the preceding 28 days: 411 men were randomized to the intervention and 414 to the control. Intervention and comparator: A series of 112 interactive text messages was delivered by mobile phone during a 12‐week period. The intervention was structured around the Health Action Process Approach, a comprehensive model which allows integration of a range of evidence‐based behaviour change techniques. The control group received 89 texts on general health, with no mention of alcohol or use of behaviour change techniques. Measurements: The primary outcome measure was the proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) at 12 months post‐intervention. Findings: The proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) was 41.5% in the intervention group and 47.8% in the control group. Formal analysis showed that there was no evidence that the intervention was effective [odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.57–1.08; absolute reduction 5.7%, 95% CI = −13.3 to 1.9]. The Bayes factor for this outcome was 1.3, confirming that the results were inconclusive. The retention was high and similar in intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged with the text messages: almost all (92%) replied to text messages and 67% replied more than 10 times. Conclusions: A theoretically based text‐messaging intervention aimed at reducing binge drinking in disadvantaged men was not found to reduce prevalence of binge drinking at 12‐month follow‐up.

Introduction and Aims Disadvantaged men suffer substantial harm from heavy drinking. This feasibility study developed and evaluated the methods for a trial of a brief intervention delivered by text messages to disadvantaged men. It aimed to test the methods for recruitment and retention, to monitor engagement with the intervention and assess the overall acceptability of study methods. Design and Methods Disadvantaged men aged 25–44 years who had ≥2 episodes of binge drinking (≥8 units in one session) in the preceding month were recruited. Two recruitment strategies were assessed: recruitment from general practice registers and by a community outreach strategy. Theoretically and empirically based text messages were tailored to the target group. Results The study recruited 67 disadvantaged men at high risk of alcohol-related harm, exceeding the target of 60. Evaluation showed that 95% of text messages were delivered, and the men engaged enthusiastically with the intervention. Retention at follow up was 96%. Outcomes were successfully measured on all men followed up. This provided data for the sample size calculation for the full trial. Post-study evaluation showed high levels of satisfaction with the study. Discussion and Conclusions This study has shown that disadvantaged men can be recruited and follow-up data obtained in an alcohol intervention study. The study methods were acceptable to the participants. The men recruited were at high risk of alcohol-related harms. It also clarified ways in which the recruitment strategy, the baseline questionnaire and the intervention could be improved. The full trial is currently underway. [Crombie IK, Irvine L, Falconer DW, Williams B, Ricketts IW, Jones C, Humphris G, Norrie J, Slane P, Rice P. Alcohol and disadvantaged men: A feasibility trial of an intervention delivered by mobile phone. Drug Alcohol Rev 2017;36:468-476]

Background Socially disadvantaged men are more likely to binge drink frequently and to experience high levels of alcohol-related harm. Objectives To test the effectiveness and cost-effectiveness of a text message intervention in reducing the frequency of binge drinking among disadvantaged men. Study design A four-centre, parallel-group, pragmatic, individually randomised controlled trial was conducted. Randomisation was carried out using a secure remote web-based system. It was stratified by participating centre and recruitment method and restricted using block sizes of randomly varying lengths. Setting The study was conducted in the community. Members of the public helped to develop the study methods. Participants Participants were men aged 25–44 years who had ≥ 2 episodes of binge drinking (> 8 units of alcohol in a single session) in the preceding 28 days. Men were recruited from areas of high deprivation. Interventions An empirically and theoretically based text message intervention was delivered by 112 interactive text messages over a 12-week period. The control group received an attentional control comprising 89 text messages on general health. Primary outcome measure The primary outcome measure was the proportion of men consuming > 8 units of alcohol on ≥ 3 occasions (in the previous 28 days) at 12 months post intervention. Results The recruitment target of 798 was exceeded and 825 men were randomised. Retention was high and similar in the intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged enthusiastically with the text messages: almost all (92%) replied to text messages and over two-thirds (67%) replied more than 10 times. The intervention was estimated to have had a modest, statistically non-significant effect on the primary outcome at the 12-month follow-up [odds ratio 0.79, 95% confidence interval (CI) 0.57 to 1.08]. This corresponds to a net reduction of 5.7% in regular binge drinking. Five secondary outcomes showed small non-significant and inconsistent effects on alcohol consumption, with one suggesting a positive effect and four suggesting an adverse effect. Both the short- and the long-term cost per quality-adjusted life-year (QALY) analysis suggested that the brief intervention was dominated by a ‘do-nothing’ option. The intervention’s impacts on patterns of alcohol consumption, QALYs and downstream costs were inconsistent and uncertain. Limitations The study used an active control that, combined with the recruitment procedures and baseline assessments, could have biased the treatment effect towards the null. The measurement of alcohol consumption relied on self-reported drinking. Conclusions The trial has demonstrated that it is possible to recruit and retain large numbers of socially disadvantaged men in a research study. The text messages delivered a complex theoretically and empirically based intervention that fostered enthusiastic engagement with the key components of the behaviour change sequence. The intervention produced a modest, statistically non-significant effect on the primary outcome, with wide CIs. Further research is needed to reduce uncertainty about the treatment effect. The methods developed for this study provide a platform for the design and testing of interventions to reduce inequalities in health. Future work A future trial could reduce the uncertainty around the treatment effect of the intervention. Trial registration Current Controlled Trials ISRCTN07695192. Funding This study was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 6. See NIHR Journals Library website for further information.

This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 12/139/ 12). Objectives Being obese and drinking more than 14 units of alcohol per week places men at very high risk of developing liver disease. This study assessed the feasibility of a trial to reduce alcohol consumption. It tested the recruitment strategy, engagement with the intervention, retention and study acceptability. Methods Men aged 35–64 years who drank >21 units of alcohol per week and had a BMI > 30 were recruited by two methods: from GP patient registers and by community outreach. The intervention was delivered by a face to face session followed by a series of text messages. Trained lay people (Study Coordinators) delivered the face to face session. Participants were followed up for 5 months from baseline to measure weekly alcohol consumption and BMI. Results The recruitment target of 60 was exceeded, with 69 men recruited and randomized. At baseline, almost all the participants (95%) exceeded the threshold for a 19-fold increase in the risk of dying from liver disease. The intervention was delivered with high fidelity. A very high follow-up rate was achieved (98%) and the outcomes for the full trial were measured. Process evaluation showed that participants responded as intended to key steps in the behaviour change strategy. The acceptability of the study methods was high: e.g. 80% of men would recommend the study to others. Conclusions This feasibility study identified a group at high risk of liver disease. It showed that a full trial could be conducted to test the effectiveness and cost-effectiveness of the intervention. Trial registration Current controlled trials: ISRCTN55309164. Trial funding National Institute for Health Research Health Technology Assessment (NIHR HTA). Short summary This feasibility study recruited 69 men at high risk of developing liver disease. The novel intervention, to reduce alcohol consumption through the motivation of weight loss, was well received. A very high follow-up rate was achieved. Process evaluation showed that participants engaged with key components of the behaviour change strategy. Publisher PDF

Purpose: \ud \ud This study identified the extent and nature of engagement with a theoretically based behaviour change text message intervention intended to reduce binge drinking. The data were from a randomised controlled trial tackling binge drinking among socially disadvantaged men.\ud \ud Method: \ud \ud An intervention, comprising 112 text messages, and based on the principles of the Health Action Process Approach, was delivered to 411 socially disadvantaged men. Participants sent almost 7500 responses to the text messages. Engagement was assessed by whether text message replies showed the intended response to key components of the behaviour change strategy.\ud \ud Results: \ud \ud The median number of responses to the text messages was 17 per man (range 0–81). Men often gave detailed sensitive personal information about their drinking and the harms it caused them. They also described their attempts at drinking less, the setbacks encountered and the benefits they enjoy when they are successful at cutting down. Specific examples of engagement with the targeted messages include the following: of the 248 men who responded to the prompt on outcome expectancies, most (230) identified potential benefits of cutting down; for intention to reduce drinking, 260 men responded of whom 44% said they had thought about changing; of the 172 men who responded to the question on goal setting, 158 reported personal goals.\ud \ud Conclusions: \ud \ud The responses showed that most men engaged as intended with the key components of the intervention. Text message interventions should include questions addressing key components of the behaviour change strategy to determine whether there is effective engagement with intervention components.

BackgroundYoung women frequently drink alcohol in groups and binge drinking within these natural drinking groups is common. This study describes the design of a theoretically and empirically based group intervention to reduce binge drinking among young women. It also evaluates their engagement with the intervention and the acceptability of the study methods.MethodsFriendship groups of women aged 18–35 years, who had two or more episodes of binge drinking (>6 UK units on one occasion; 48g of alcohol) in the previous 30 days, were recruited from the community. A face-to-face group intervention, based on the Health Action Process Approach, was delivered over three sessions. Components of the intervention were woven around fun activities, such as making alcohol free cocktails. Women were followed up four months after the intervention was delivered. Results The target of 24 groups (comprising 97 women) was recruited. The common pattern of drinking was infrequent, heavy drinking (mean consumption on the heaviest drinking day was UK 18.1 units). Process evaluation revealed that the intervention was delivered with high fidelity and acceptability of the study methods was high. The women engaged positively with intervention components and made group decisions about cutting down. Twenty two groups set goals to reduce their drinking, and these were translated into action plans. Retention of individuals at follow up was 87%.ConclusionsThis study successfully recruited groups of young women whose patterns of drinking place them at high risk of acute harm. This novel approach to delivering an alcohol intervention has potential to reduce binge drinking among young women. The high levels of engagement with key steps in the behavior change process suggests that the group intervention should be tested in a full randomised controlled trial.

To test the effectiveness of a theoretically based text-message intervention to reduce binge drinking among socially disadvantaged men.A multi-centre parallel group, pragmatic, individually randomized controlled trial.Community-based study conducted in four regions of Scotland.A total of 825 men aged 25-44 years recruited from socially disadvantaged areas who had two or more episodes of binge drinking ( 8 UK units on a single occasion) in the preceding 28 days: 411 men were randomized to the intervention and 414 to the control.A series of 112 interactive text messages was delivered by mobile phone during a 12-week period. The intervention was structured around the Health Action Process Approach, a comprehensive model which allows integration of a range of evidence-based behaviour change techniques. The control group received 89 texts on general health, with no mention of alcohol or use of behaviour change techniques.The primary outcome measure was the proportion of men consuming 8 units on three or more occasions (in the previous 28 days) at 12 months post-intervention.The proportion of men consuming 8 units on three or more occasions (in the previous 28 days) was 41.5% in the intervention group and 47.8% in the control group. Formal analysis showed that there was no evidence that the intervention was effective [odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.57-1.08; absolute reduction 5.7%, 95% CI = -13.3 to 1.9]. The Bayes factor for this outcome was 1.3, confirming that the results were inconclusive. The retention was high and similar in intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged with the text messages: almost all (92%) replied to text messages and 67% replied more than 10 times.A theoretically based text-messaging intervention aimed at reducing binge drinking in disadvantaged men was not found to reduce prevalence of binge drinking at 12-month follow-up.

Objective To examine whether dog ownership amongst community dwelling older adults (≥ 65 years) is associated with objectively measured physical activity (PA). Methods We used data from the Physical Activity Cohort Scotland (PACS) which consists of 547 people aged 65 and over, resident in the community in Tayside, Scotland. The data was collected in 2009–2011. We assessed whether dog ownership is associated with objectively measured physical activity (accelerometry counts). Results The physical activity (PA) counts of 547 older people (mean age 79 (standard deviation (SD) 8 years, 54% female) were analysed. Linear mixed models showed that dog ownership was positively related to higher PA levels. This positive relationship remained after controlling for a large number of individual and contextual variables, including attitude towards exercise, physical activity intention and history of physical activity. Dog owners were found to be 12% more active (21,875 counts, 95% Confidence Interval (CI): 2810 to 40,939, p Conclusion Dog ownership is associated with physical activity in later life. Interventions to increase activity amongst older people might usefully attempt to replicate elements of the dog ownership experience.

BACKGROUND: Men who are socially disadvantaged are at a substantially higher risk of developing alcohol-related diseases. People from deprived areas are known to be more difficult to recruit to research studies. As part of a feasibility assessment for an intervention study, 2 recruitment strategies were investigated. This article compares the drinking patterns of the disadvantaged men identified by the 2 strategies. METHODS: A cross-sectional survey compared 2 strategies for recruiting disadvantaged men to a study on alcohol consumption: recruitment through general practice (GP) registers and through a community outreach strategy, respondent-driven sampling (RDS). Men aged 25 to 44 years were recruited from deprived areas in the community. The entry criterion was binge drinking (≥8 units in a single session) at least twice in the previous 4 weeks. Demographic characteristics, total consumption of alcohol, frequency of binge drinking (≥8 units in a session), and heavy binge drinking (≥16 units in a session) were measured. RESULTS: Men recruited by RDS drank more than twice as much as the men recruited through GP (137 units in the previous 30 days compared with 62 units; p = 0.003). They also had many more binge drinking days: more than half (57%) of men from RDS had 6 or more binge drinking days in the previous 30 days, whereas only 16% of the GP sample had 6 or more binge drinking days (p = 0.001). Many more men recruited by RDS (37% vs. 5%; p = 0.002) had more than 5 very heavy drinking sessions in the previous month (≥16 units in a session). The RDS group also had fewer alcohol-free days. CONCLUSIONS: The 2 sampling strategies recruited different types of drinkers. The men recruited through RDS were much more likely to engage in frequent harmful drinking. The results indicate that the 2 methods recruit different samples of disadvantaged men. Intervention studies that are only conducted through primary care may miss many harmful drinkers. Language: en

CITATION: Watson, R., et al. 2016. Proceedings of the 13th annual conference of INEBRIA. Addiction Science & Clinical Practice, 11:13, doi:10.1186/s13722-016-0062-9.

Introduction and Aims Disadvantaged men suffer substantial harm from heavy drinking. This feasibility study developed and evaluated the methods for a trial of a brief intervention delivered by text messages to disadvantaged men. It aimed to test the methods for recruitment and retention, to monitor engagement with the intervention and assess the overall acceptability of study methods. Design and Methods Disadvantaged men aged 25–44 years who had ≥2 episodes of binge drinking (≥8 units in one session) in the preceding month were recruited. Two recruitment strategies were assessed: recruitment from general practice registers and by a community outreach strategy. Theoretically and empirically based text messages were tailored to the target group. Results The study recruited 67 disadvantaged men at high risk of alcohol‐related harm, exceeding the target of 60. Evaluation showed that 95% of text messages were delivered, and the men engaged enthusiastically with the intervention. Retention at follow up was 96%. Outcomes were successfully measured on all men followed up. This provided data for the sample size calculation for the full trial. Post‐study evaluation showed high levels of satisfaction with the study. Discussion and Conclusions This study has shown that disadvantaged men can be recruited and follow‐up data obtained in an alcohol intervention study. The study methods were acceptable to the participants. The men recruited were at high risk of alcohol‐related harms. It also clarified ways in which the recruitment strategy, the baseline questionnaire and the intervention could be improved. The full trial is currently underway. [Crombie IK, Irvine L, Falconer DW, Williams B, Ricketts IW, Jones C, Humphris G, Norrie J, Slane P, Rice P. Alcohol and disadvantaged men: A feasibility trial of an intervention delivered by mobile phone. Drug Alcohol Rev 2017;36:468‐476]

Summary Modern-day epidemiologists are confronted with huge changes, such as the rise in the global population due to reduced mortality, migration within and across countries, massive shifts in economic standing and lifestyles, and environmental degradation. With over 1000 posters, more than 100 oral presentations, 16 workshops, four lunchtime symposia, many exhibitions and immeasurable discussions, the task of capturing all highlights of the International Epidemiology Association (IEA) World Congress of Epidemiology 2011 is impossible, but this article has provided a sample. Many presenters showed that the challenges facing global health are complex, changing and in demand of measurement, and they demonstrated the central role of epidemiology. The cutting-edge methodologies theme promised the emergence of a more transparent, better balanced, but also more critical approach to dealing with bias. Preceding the United Nations high-level meeting on non-communicable diseases (New York, 19th–20th September 2011), the Congress’s chronic diseases stream was especially timely. The neglected conditions theme illustrated inspiring work battling against apathy, inertia and ignorance; perhaps the special challenge of the ’neglected conditions epidemiologist’. Translating epidemiology’s insights into effective policies and programmes to prevent diseases or reduce their impact is not easy. Speakers highlighted the common failure of epidemiologists to contribute actively to improving the health of the populations they serve, especially the poor and disadvantaged, but also provided many examples where they had done so. The ‘other’ theme ensured that important studies were not lost from the programme just because they did not fit easily into the specific themes. The studies focused on identified risk factors throughout the life course. A variety of methods were used to identify factors that altered the rate of birth, disease and death. Ongoing epidemiology is not only broad but is also deep, and ever more so as collaborative pooling of expertise, data, populations and ideas has emerged, accelerated by modern-day communication technologies. Epidemiology, and epidemiologists, seem poised for tomorrow’s world.

Accurate pain assessment is important but presents problems in poorly resourced countries. A civil war in Sierra Leone resulted in civilian casualties with pain from deliberate amputation and other injuries.To examine the quality of simple pain and mood scales.Within a pain treatment project, pain was assessed using numerical and verbal descriptor scales, and mood using visual analogue and verbal descriptor scales. The relationships between these scales (translated where necessary) were examined by comparison of pairs of measures.The overwhelming majority (99%) used the scales consistently. The verbal pain scale showed substantial discrimination between the pain words mild/small, moderate/half and half, and severe/serious (F=41.80, P0.001). Numerical and verbal pain scales were related at a modest level (Kendall's tau-b=0.39, P0.001, n=272) and not dependent on the level of education. A smaller sample (n=30) provided pain data across three assessment occasions, and both pain scales appeared sensitive to change. The 5-point verbal mood scale collapsed into three categories, with reasonable distinction between mood words (F=14.75, P0.001). The visual analogue scale proved difficult to explain to civilian casualties in this setting.Verbal pain and mood scales and numerical pain scales appeared to yield useful information in a post-conflict situation. This suggests that adapting these established rating scales for pain, and for mood, was useful to clinicians and acceptable to patients.

This systematic review assesses weight loss interventions in young adults (18-25 years), who are vulnerable to weight gain. This age group experience critical life course points (leaving home for higher studies or job, pregnancy, cohabitation) and develop/establish lifestyle and behavioural patterns making this an opportune intervention period. Medline, Embase, Cinahl, PsychINFO and Cochrane Library were searched (1980 to March 2008). All trials and cohort studies with control groups that assessed weight loss interventions in this specific age group were included finally identifying 14 studies. Before and after comparison of behavioural/motivational interventions (-2.40 kg; 95% CI -5.4 to 0.6) and combination interventions (-2.96; 95% CI -4.4 to -1.5) consistently showed weight loss. Behavioural/motivational interventions increased self-efficacy, the desire to control weight, boosted self-esteem, and increased satisfaction with body areas and appearance. Interventions also showed improvements in HDL cholesterol, insulin, glucose and maximum oxygen uptake. However, recruitment to participation in interventions was a barrier for this age group with small sample sizes and short-term interventions. There may be gender differences in preference to participation in certain type of interventions. Further research to understand attitudes towards healthy lifestyle and preferences of interventions is needed to develop suitable interventions for this vulnerable age group.

ObjectiveTo investigate the maternal factors associated with poor diet among disadvantaged children.DesignSurvey of 300 mothers of 2-year-old children from areas of high deprivation in Scotland (response rate 81 %). A diet quality score was derived from reported consumption of carbohydrates, protein, fruit and vegetables, dairy products and restriction of sugary fatty foods.ResultsMost children (85 %) were classified as having a poor quality diet (low diet quality score). Mothers’ general knowledge about healthy eating was high, but did not predict the quality of the children’s diet. Lower frequencies of food preparation and serving, such as cooking with raw ingredients, providing breakfast daily and the family eating together, were also associated with a poorer diet. Regression modelling identified five significant factors. An increased risk of a poor diet was associated with mothers being unlikely to restrict sweets (OR = 21·63, 95 % CI 2·70, 173·30) or finding it difficult to provide 2–3 portions of fruit daily (OR = 2·94, 95 % CI 1·09, 7·95). Concern that the child did not eat enough increased the risk of a poor diet (OR = 2·37, 95 % CI 1·09, 5·16). Believing a healthy diet would help the child eat more reduced the risk of having a poor diet (OR = 0·28, 95 % CI 0·11, 0·74), as did providing breakfast daily (OR = 0·22, 95 % CI 0·05, 0·99).ConclusionsInterventions to improve children’s diet could promote more positive intentions about preparing and serving of foods, particularly of specific meals at which the family eats together. The benefits of these behaviours to the child (improved diet, weight control) should be emphasised.

Edinburgh and Glasgow are the two largest cities in Scotland, which has one of the highest coronary heart disease mortality rates in the world. Within Scotland, there is a geographical variation in these rates and Glasgow has a higher mortality rate than Edinburgh. However, the cities also differ socially and economically. Population surveys have been conducted in centres in both Edinburgh and North Glasgow using the MONICA project methods. These surveys were performed simultaneously in 1986 in men and women aged 25–64 years. Preliminary analysis shows that the differences in cigarette smoking, blood pressure and body mass index in men and women between the two centres are consistent with the difference in cardiovascular mortality. However there is no difference between the centres in reported exercise levels, and the difference in mean serum total cholesterol between the centres is in the opposite direction to that expected. Possible explanations of these differences are discussed.

Public health policy underwent substantial transformation during the latter half of the 20th century. The landmark statement was the 1948 World Health Organization (WHO) constitution, which identified good health as a fundamental right and gave the responsibility to governments to achieve it for all their people. However, following World War II, developed countries made substantial investment in health care with less attention paid to public health. The importance of public health was slowly recognised over the period from 1970 to 2000 with the publication of several reports from different organisations. The first authoritative policy statement that the important determinants of health lay outside health care was in the Lalonde Report from Canada. These ideas were subsequently expressed in the WHO Alma-Ata declaration and were emphasised a year later by the US Surgeon General. The idea of setting goals for health improvement also began in the 1970s. The Lalonde Report and the United Kingdom Black Report recommended that targets be used, but the first explicitly stated health targets were set by the US in 1979. WHO also identified the need for such targets at this time, but did not introduce them until 1984. Since then health targets have become a central feature of public health policy in developed countries. The Ottawa Conference on Health Promotion in 1986 championed the view that health promotion was central to achieving health goals internationally. It helped clarify the types of actions needed: that individuals need to be provided with the supportive environment and economic resources to be able to lead healthy lives. In a further development, the Healthy Cities Project was launched with the specific aim of involving political decision-makers in building a strong lobby for public health at the local level. The Healthy Cities Project illustrates how to provide means and opportunity for interventions to be implemented in communities. Concerns with inequalities in health were emphasised in the WHO declaration of Alma-Ata, and were the focus of the United Kingdom Black Report. The Jakarta Conference on Health Promotion in 1997 urged international action on poverty, as it is the major threat to health. International acceptance of the need to tackle inequalities took longer than the acceptance of health targets, but it is now an important feature of public health policy. The advent of the 21st century marked the coming of age of public health. The renewed version of ‘Health for All’, ‘Health for All in the 21st Century’, emphasised the one constant goal of WHO that all individuals should achieve their full health potential. Public health is now regarded internationally as being a priority with this WHO goal being adopted as the overarching goal of policy. The challenges it faces in tackling problems such as obesity, inequalities in health, smoking, alcohol and substance abuse are great and will require policies which tackle the economic, social and environmental determinants of health.

Background Socially disadvantaged men are at a substantially higher risk of developing alcohol-related problems. The frequency of heavy drinking in a single session is high among disadvantaged men. Brief alcohol interventions were developed for, and are usually delivered in, healthcare settings. The group who binge drink most frequently, young to middle-aged disadvantaged men, have less contact with health services and there is a need for an alternative method of intervention delivery. Text messaging has been used successfully to modify other adverse health behaviours. This study will test whether text messages can reduce the frequency of binge drinking by disadvantaged men. Methods/design Disadvantaged men aged 25 to 44 years who drank >8 units of alcohol at least twice in the preceding month will be recruited from the community. Two recruitment strategies will be used: contacting men listed in primary care registers, and a community outreach method (time-space sampling). The intended sample of 798 men will be randomised to intervention or control, stratifying by recruitment method. The intervention group will receive a series of text messages designed to reduce the frequency of binge drinking through the formation of specific action plans. The control group will receive behaviourally neutral text messages intended to promote retention in the study. The primary outcome measure is the proportion of men consuming >8 units on at least three occasions in the previous 30 days. Secondary outcomes include total alcohol consumption and the frequency of consuming more than 16 units of alcohol in one session in the previous month. Process measures, developed during a previous feasibility study, will monitor engagement with the key behaviour change components of the intervention. The study will incorporate an economic evaluation comparing the costs of recruitment and intervention delivery with the benefits of reduced alcohol-related harm. Discussion This study will assess the effectiveness of a brief intervention, delivered by text messages, aimed at reducing the frequency of binge drinking in disadvantaged men. The process measures will identify components of the intervention which contribute to effectiveness. The study will also determine whether any benefit of the intervention is justified by the costs of intervening. Trial registration ISRCTN07695192. Date assigned: 14 August 2013.

PURPOSE Depression is common in primary care. There are no systematic reviews of depression treatment comparing antidepressants with placebo; hence, we do not know whether these medications are effective in primary care. METHODS We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Group register of controlled trials, MEDLINE, International Pharmaceuti- cal abstracts, PsycINFO, and EMBASE. Abstracts of potential studies were reviewed independently by 2 authors. Studies needed to include randomized controlled tri- als of either a tricyclic antidepressant (TCA) or selective serotonin reuptake inhibi- tor (SSRI), or both, and placebo in a primary care setting. The data and quality of the studies were extracted and assessed by 2 authors blind to the other's choice. Disagreements were resolved by discussion. The main outcome measures were the standardized mean difference and weighted mean difference of the fi nal mean depression scores, the relative risk of improvement, and the number withdrawing because of side effects. Pooling of results was done using Review Manager 4.2.2. RESULTS There were 10 studies in which TCAs were compared with placebo, 3 in which SSRIs were compared with placebo, and 2 with both compared with pla- cebo. One half of the studies were of low methodological quality, and nearly all studies were of short duration, typically 6 to 8 weeks. Pooled estimates of effi cacy data showed a relative risk of 1.26 (95% CI, 1.12-1.42) for improvement with TCAs compared with placebo; For SSRIs, relative risk was 1.37 (95% CI, 1.21- 1.55). Most patients, 56% to 60%, responded well to active treatment compared with 42% to 47% for placebo. The number needed to treat for TCAs was about 4, and for SSRIs it was 6. The numbers needed to harm (for withdrawal caused by side effects) ranged from 5 to 11 for TCAs and 21 to 94 for SSRIs. Low-dose (100 mg or 75 mg) as well as high-dose TCAs were effective. CONCLUSION This systematic review is the fi rst comparing antidepressants with placebo for treatment of depression in primary care. Both TCAs and SSRIs are effective. This review is also the fi rst to show that low-dose TCAs are effective in primary care. Prescribing antidepressants in primary care is a more effective clini- cal activity than prescribing placebo.

Background: cranberry juice is often given to older people in hospital to prevent urinary tract infection (UTI), although there is little evidence to support its use. Objective: to assess whether cranberry juice ingestion is effective in reducing UTIs in older people in hospital. Design: randomised, placebo-controlled, double-blind trial. Setting: Medicine for the Elderly assessment and rehabilitation hospital wards. Subjects: 376 older patients in hospital. Methods: participants were randomised to daily ingestion of 300 ml of cranberry juice or matching placebo beverage. The primary outcome was time to onset of first UTI. Secondary outcomes were adherence to beverage drinking, courses of antibiotics prescribed, and organisms responsible for UTIs. Results: a total of 21/376 (5.6%) participants developed a symptomatic UTI: 14/189 in the placebo group and 7/187 in the cranberry juice group. These between-group differences were not significant, relative risk (RR) 0.51 [95% CI 0.21–1.22, P = 0.122). Although there were significantly fewer infections with Escherichia coli in the cranberry group (13 versus 4) RR 0.31 [95% CI 0.10–0.94, P = 0.027], this should be interpreted with caution as it was a secondary outcome. Conclusion: despite having the largest sample size of any clinical trial yet to have examined the effect of cranberry juice ingestion, the actual infection rate observed was lower than anticipated, making the study underpowered. This study has confirmed the acceptability of cranberry juice to older people. Larger trials are now required to determine whether it is effective in reducing UTIs in older hospital patients.

Summary The Walker cohort is a database of over 48 000 birth records that has recently become available. It contains meticulously recorded details of pregnancy, labour, birth and care before discharge for babies born in hospital in Dundee, Scotland between 1952 and 1966. These babies accounted for 75% of all births in Dundee at this time. Over 34 000 (73%) of these subjects can be identified and this presents the opportunity to link this birth information with a large number of current health-outcome databases covering both primary and secondary care. Further, it allows linkage of records across siblings and over two and, in future, three generations. The number of birth records available and linkage to current databases make this a unique birth cohort with huge potential for the investigation of the fetal origins of adult disease.

Background Regular physical activity has been shown to have many health benefits. However, many older people are physically inactive. Objective To investigate why older people are reluctant to participate in leisure time physical activity and to identify strategies to encourage increased activity. Design Cross-sectional survey. Setting 16 general practices in Dundee, Scotland. Methods 409 randomly selected older people (65-84 years) who lived independently were interviewed at home. Forty-six percent of those invited to take part were recruited into the study. Results Levels of knowledge about the specific health benefits of physical activity were high. Almost all participants (95%) believed that physical activity was beneficial and 79% believed that they did enough to keep healthy. However, 36% did no leisure time physical activity and a further 17% did less than 2 hours per week. Regression modelling identified 11 factors that exerted significant independent effects on levels of leisure time physical activity. The most powerful deterrent was lack of interest (OR = 7.8). Other factors included lack of daily access to a car, shortness of breath, joint pain, dislike of going out alone or in the evening, perceived lack of fitness, lack of energy, doubting that exercise can lengthen life, not belonging to a group and doubting that meeting new people is beneficial. Conclusions Increasing leisure time physical activities poses major challenges. Beliefs about desirable levels of activity in older people would need to be changed. Action would be needed to relieve physical symptoms and address fears about perceived ability to undertake physical activity. Finally, easily accessible facilities would be needed to encourage participation in physical activity.

Background. In 1999 the Scottish Office, United Kingdom, intimated that the Chief Nursing Officer would undertake a policy review of nurses’ contribution to improving the public's health. The importance of reviewing the scientific literature on the effectiveness of public health nursing was recognized as a crucial part of the policy review. A final report was expected within a 6-month period. The reason for the short time period was to fit the policy-making schedule. This paper discusses our literature review for this work. Aims. The aim was to conduct a review of the international scientific literature that gave the greatest coverage of the role and potential role of nurses in improving the public's health in relation to 14 major health topics. This paper describes the methods used, outlines the rationale underpinning the methods, discusses the problems encountered and offers solutions to some of these problems. Methods. The initial search for relevant scientific literature revealed 709 suitable primary papers. Reviewing this number was beyond the time limit set by the funding organization. Therefore, a decision was made to concentrate on the evidence contained in systematic reviews. Reviewing systematic reviews raises a number of methodological problems to which there are often no predetermined solutions, such as ensuring that important interventions are included, assessing the relevance and quality of the reviews, and grading the strength of the evidence. Discussion. Reviewing systematic reviews provides the scope to increase the number of topics that might be covered. However, it is possible that a number of interventions may be missed, particularly those that are not subject to review or those assessed using qualitative techniques. The definition of public health nursing used in the present study was also restrictive, and could be widened to include community interventions. Finally, assessing the quality of reviews and grading the evidence proved difficult and there is lack of consensus on how these tasks should be achieved. Nevertheless, the review presented policy makers with accessible information on a large number of relevant international studies.

Background . The number of voluntary organizations active in health care is considerable. There have been recent calls for a new closer working relationship between voluntary bodies and the National Health Service. The relationship between the two healthcare sectors needs to be efficient and harmonious in the interests of patient care; however, little is known about the nature and problems in the current relationship. The present study was undertaken to examine aspects of this relationship from the point of view of health board personnel. Objective . To identify the practices and views of Scottish health board staff concerning the funding, role and responsibility of voluntary organizations in the health sector. Methods . A qualitative study based on in-depth interviews with health board officials in all 15 Scottish health boards. Results . Policies for financial and other relationships with the voluntary sector were often not explicit. The levels and method of funding voluntary health organizations varied across boards, as did the tenure of awards (from 1 to 3 years). Demand for funding far exceeded monies available. Some health boards ensured accountability through audited accounts, annual reports and site visits; however, others thought this inappropriate for small organizations. Health boards recognized the problems of the precariousness of funding and the administrative burden of the monitoring process and the ritual of applying for funding. Conclusion . The uncertainties of long-term funding may impede the contribution of voluntary organizations. There is a tension between the requirements of clinical governance and the ability of small voluntary organizations to provide the necessary documentation. One proposed solution, to reduce the number of organizations, might not appeal to the voluntary sector. Future initiatives could address the problem of tailoring funding and accounting to the resources of voluntary organizations.

Aims To test the hypothesis that urate predicts cardiac death after stroke independent of conventional risk factors of atherosclerosis, creatinine and diuretic use. Methods and Results Serum urate concentration was measured in an unselected cohort of 354 stroke survivors who were followed-up for a median of 2·8 years. Cardiac death was the primary end-point. Urate was associated with a statistically significant threefold increase in relative risk of cardiac death even after adjustment for other conventional risk factors. In the subgroup of patients who were not on diuretics, raised urate was associated with a 12-fold significant increase in relative risk of cardiac death after adjusting for renal function and other conventional risk factors. A urate concentration of greater than 0·31mmol.l−1 was 78% sensitive at predicting cardiac death within 5 years after stroke, but was only 54% specific. If urate exceeded 0·38mmol.l−1, specificity of predicting cardiac death within 5 years after stroke was 88%. Conclusions Elevated serum urate concentration may be used to stratify risk of future cardiac death after stroke. This appeared to be true even in stroke survivors who were not on diuretic therapy.

This study was funded by Scottish Executive grant CZH/4/518. The sponsor was the University of Dundee. Background: Weather is a potentially important determinant of physical activity. Little work has been done examining the relationship between weather and physical activity, and potential modifiers of any relationship in older people. We therefore examined the relationship between weather and physical activity in a cohort of older community-dwelling people. Methods: We analysed prospectively collected cross-sectional activity data from community-dwelling people aged 65 and over in the Physical Activity Cohort Scotland. We correlated seven day triaxial accelerometry data with daily weather data (temperature, day length, sunshine, snow, rain), and a series of potential effect modifiers were tested in mixed models: environmental variables (urban vs rural dwelling, percentage of green space), psychological variables (anxiety, depression, perceived behavioural control), social variables (number of close contacts) and health status measured using the SF-36 questionnaire. Results: 547 participants, mean age 78.5 years, were included in this analysis. Higher minimum daily temperature and longer day length were associated with higher activity levels; these associations remained robust to adjustment for other significant associates of activity: age, perceived behavioural control, number of social contacts and physical function. Of the potential effect modifier variables, only urban vs rural dwelling and the SF-36 measure of social functioning enhanced the association between day length and activity; no variable modified the association between minimum temperature and activity. Conclusions: In older community dwelling people, minimum temperature and day length were associated with objectively measured activity. There was little evidence for moderation of these associations through potentially modifiable health, environmental, social or psychological variables. Publisher PDF

Sampling, or selecting a group of people to represent a whole population, lies at the heart of almost all research designs. There are many ways of going about this, each of which presents its own problems. The trick is to obtain a good-sized sample that is truly representative of the population as a whole.

Screening has generally been successful in identifying those at risk from disease. This success has led to the belief that screening in the general population is always a good thing. However, there are pitfalls which must be avoided if screening programmes are to achieve what is intended for them.

Objective—To review the literature on the benefits and disadvantages of clinical and medical audit, and to assess the main facilitators and barriers to conducting the audit process. Design—A comprehensive literature review was undertaken through a thorough review of Medline and CINAHL databases using the keywords of “audit”, “audit of audits”, and “evaluation of audits” and a handsearch of the indexes of relevant journals for key papers. Results—Findings from 93 publications were reviewed. These ranged from single case studies of individual audit projects through retrospective reviews of departmental audit programmes to studies of interface projects between primary and secondary care. The studies reviewed incorporated the experiences of a wide variety of clinicians, from medical consultants to professionals allied to medicine and from those involved in unidisciplinary and multidisciplinary ventures. Perceived benefits of audit included improved communication among colleagues and other professional groups, improved patient care, increased professional satisfaction, and better administration. Some disadvantages of audit were perceived as diminished clinical ownership, fear of litigation, hierarchical and territorial suspicions, and professional isolation.The main barriers to clinical audit can be classified under five main headings.These are lack of resources, lack of expertise or advice in project design and analysis,problems between groups and group members, lack of an overall plan for audit, and organisational impediments. Key facilitating factors to audit were also identified: they included modern medical records systems, eVective training, dedicated staV, protected time, structured programmes, and a shared dialogue between purchasers and providers. Conclusions—Clinical audit can be a valuable assistance to any programme which aims to improve the quality of health care and its delivery. Yet without a coherent strategy aimed at nurturing eVective audits, valuable opportunities will be lost. Paying careful attention to the professional attitudes highlighted in this review may help audit to deliver on some of its promise.

There is growing interest in using health outcomes data from large observational databases to assess the impact of interventions or the performance of services. The wefilness of such data hinges on being able to make attributions of causality between the interventions or services and the observed outcomes. Unfortunately, there are many reasons why such attributions are undermined by methodological difficulties. The findings from outcomes studies may conflict across a broad set of measures and the outcomes measures themselves may lack reliability and validity, especially as they are usually collected unblinded. Differences in case-mix make the use of severity adjustment schemes essential but such adjustments are inevitably incomplete. In addition, case-mix adjustment adds increasing data demanak and runs the risk of introducing upstaging. Further, different schemes may lead to different judgments, and unaajusted case-mix differences may still confound the findings. Finally, chance variability may lead to spurious findings or even hide important differences. Thus, there are many reasons to doubt attributions of causality between observations and interventions and such data require circumspect interpretation.

Surgery and trauma are recognised as important causes of chronic pain, although their overall contribution has not been systematically studied. This paper reports on the contribution of surgery and trauma to chronic pain among 5130 patients attending 10 outpatient clinics located throughout North Britain. Surgery contributed to pain in 22.5% of patients, and was particularly associated with the development of pain in the abdomen and with anal, perineal and genital pain. Trauma was a cause of pain in 18.7% of patients, and was most common in pain in the upper limb, the spine and the lower limb. Patients with chronic pain associated with trauma are on average younger than those with chronic post-surgical pain. Further, and unusually for pain conditions, the trauma patients show an excess of males over females. These findings indicate that it can be unhelpful for pain classification systems to combine surgery and trauma in a single category. The results also point to areas for potentially fruitful research into the aetiology of chronic pain. In particular, studies are needed to identify the operative procedures associated with the development of pain so that preventive measures can be implemented.

Chronic pain patients have complex problems. Due to this, much research effort has been expended on the classification of pain patients and the classification of pain problems. A mainstay of most pain classification systems is the use of the physical location of the pain. Yet describing the location of the patient's pain is not straightforward. Many patients have pain at multiple sites and thus simple statements such as 'patients with low back pain' have considerable ambiguity. Does the statement refer to patients with pain just in the lower back or those with low back pain who may also have pain elsewhere (e.g. pain down the leg)? If patients do have pain elsewhere, at what other body sites and what are the implications of this? This paper presents data on the body location of pain for a large sample of 5279 patients seen with chronic pain in Scotland and the north of England. It shows that one-third of patients have pain in multiple locations, and that using a single body site to classify patients leads to groups with large overlaps. Thus, 38% of patients reported pain in the 'lower back/spine' and 34% reported pain in the 'buttock, leg, foot' - but there was considerable overlap between these groups. Nineteen percent of patients reported pain in both of these body areas, and one-third of these patients also had pain in at least one further body area. Furthermore, a systematic look at patients with diverse physical pain locations but a single site in common shows large demographic differences. Common pain groupings help to reduce the confusion; 13 pain site descriptions were able to account for 82% of all patients. The remaining 18% of patients had pain in a combination of body sites which they shared with fewer than 1% of other patients. Thus, pain patients are widely heterogeneous and complex. Patients report pain in more complex patterns than can easily be captured by a single body-site code. Further, large demographic differences between patients with different painful sites, even when they have at least one pain site in common, suggests that grouping patients based on a single site descriptor may be inappropriate. These findings have important implications for chronic pain description and classification. Copyright 1998 European Federation of Chapters of the International Association for the Study of Pain.

The use of process measures in the assessment of the quality of care has been neglected of late. The outcomes movement has gathered momentum and process measurement appears to have been left trailing in the wake. Yet process measures can be sensitive indicators of the quality of care and have many advantages over outcomes. They are readily measured and can easily be interpreted; comparisons are not essential (as they are with outcomes monitoring) but even if used they are little bothered by the case-mix arguments which bedevil outcomes assessment. Further, the direct measurement of process can directly indicate deficiencies of care which need to be remedied. Finally, there are some aspects of care which are only amenable to study using measures of process. These benefits come at a price: first there must be good evidence that links the processes of care to desirable outcomes. This paper explores the advantages of measuring processes of care in quality assessment and advocates a balanced approach to the process vs. outcome debate.

BACKGROUND: Children with parents who smoke are often exposed to high levels of environmental tobacco smoke, and children with asthma are particularly susceptible to the detrimental effects of passive smoking. Data were collected from parents who smoke and from their asthmatic children. The families are currently taking part in a randomised controlled trial to test an intervention designed to reduce passive smoking in children with asthma. This paper reports on the baseline data. Questionnaire data and cotinine levels were compared in an attempt to assess exposure and to identify factors which influence exposure of the children. The aim of the study was to identify the scope for a reduction in passive smoking by these children. METHODS: A sample of 501 families with an asthmatic child aged 2-12 years was obtained. Factors influencing passive smoking were assessed by interviewing parents. Cotinine levels were measured from saliva samples using gas liquid chromatography with nitrogen phosphorous detection. RESULTS: Cotinine levels in children were strongly associated with the age of the child, the number of parents who smoked, contact with other smokers, the frequency of smoking in the same room as the child, and crowding within the home. Parental cotinine levels, the amount smoked in the home, and whether the home had a garden also exerted an independent effect on cotinine levels in the children. CONCLUSIONS: Many children are exposed to high levels of environmental tobacco smoke and their cotinine levels are heavily dependent upon proximity to the parent who smokes. Parents who smoke have a unique opportunity to benefit their child's health by modifying their smoking habits within the home.

Interest in outcomes is universal. To patients, good outcomes represent their highest hopes for therapy; to health care professionals, good outcomes are the desired end-point of a complex web of care. More recently, politicians and health care managers too have shifted their emphasis away from health service activity and towards what is termed 'health gain'. The rise of the outcomes movement appears irresistible. However, the difficulties in interpreting outcomes data will not go away. Outcomes measured using routine data are subject to numerous biases and many practical difficulties. Despite recent statistical, methodological and technological advances, comparisons of outcomes at best provide us with weak evidence of either the effectiveness or the quality of health care. And sometimes they may frankly mislead. The apparent intuitiveness of outcomes monitoring has broad public appeal. But enthusiasm for outcomes needs to be tempered with a clear understanding of their limitations.

In the United Kingdom patients with chronic pain are frequently managed in anaesthetist-led outpatient pain clinics. In many of these clinics the emphasis is on medical therapies (analgesics and psychotropic drugs, TENS, acupuncture and nerve blocks) with patients trying a series of different therapies until relief is achieved or further attempts at physical treatments are discontinued. The sequential trial of different treatment modalities presents clinicians with a problem. Patients who receive little benefit from (say) the first three treatments tried might be expected to be less likely to gain benefit from the next treatment modality. The presence or absence of such 'diminishing returns' from treatment will influence when therapeutic efforts based on the medical model of pain should be abandoned. This study examined basic outcome data on 1912 patients seen in a single Scottish pain clinic between 1987 and 1994. The data were analysed to assess whether the success of treatment modalities depended on whether they were used as a first-choice treatment or were given after previous therapeutic attempts had failed. Diminution in success rates was generally not large although this varied between therapies. No fall-off in success rates was seen for antidepressants, acupuncture or sympathetic nerve blocks. However, the other nerve blocks all showed falling success rates when they were used as fourth- or fifth-line treatments. That little diminution of success rates was seen warrants further investigation. Pain clinics need good information on the success or otherwise of late treatment so that they can devise rational pain management strategies covering multiple therapies and appropriate criteria for ending medical interventions. These findings suggest that allowing patients access to multiple pain therapies may well be an appropriate management strategy.

Objective: to test the predictive utility of perceived barriers to objectively measured physical activity levels in a stratified sample of older adults when accounting for social-cognitive determinants proposed by the Theory of Planned Behaviour (TPB), and economic and demographic factors. Methods: data were analysed from the Physical Activity Cohort Scotland survey, a representative and stratified (65–80 and 80+ years; deprived and affluent) sample of 584 community-dwelling older people, resident in Tayside, Scotland. Physical activity was measured objectively by accelerometry. Results: perceived barriers clustered around the areas of poor health, lack of interest, lack of safety and lack of access. Perceived poor health and lack of interest, but not lack of access or concerns about personal safety, predicted physical activity after controlling for demographic, economic and TPB variables. Discussion: perceived person-related barriers (poor health and lack of interest) seem to be more strongly associated with physical activity levels than perceived environmental barriers (safety and access) in a large sample of older adults. Perceived barriers are modifiable and may be a target for future interventions.

BackgroundSocially disadvantaged men suffer substantial harm from heavy drinking. Brief alcohol interventions are effective in reducing consumption when delivered via health care. There is a need for tailored brief interventions for disadvantaged men who seldom attend health care.Objectives(1) To investigate the best ways to recruit and retain disadvantaged men in a study aimed at reducing the frequency of heavy drinking. (2) To identify the type of content and timing of the delivery that is most likely to engage disadvantaged young to middle-aged men in an intervention delivered by text messages. (3) To determine whether or not the intervention is likely to be an acceptable way to influence the frequency of heavy drinking.DesignA three-phase study involving the development of the recruitment strategy and the intervention, an assessment of the feasibility of a randomised controlled trial, and a post-study evaluation.SettingCommunity-based study, conducted in Dundee, UK.ParticipantsDisadvantaged men aged 25–44 years who had two or more episodes of heavy drinking (≥ 8 units in a single session) in the preceding month. Two recruitment strategies were employed: recruitment through general practice (GP) registers and recruitment through a community outreach strategy.InterventionsFocus groups explored drinking motives and behaviours of the target group. The intervention also drew on reviews of the literature on: alcohol brief interventions, text message studies, communication theory and behaviour change theories and techniques. The intervention group received 36 text messages with images sent over a 28-day period.Main outcome measuresThe outcome measures evaluated the likely success of a full trial: recruitment of the participants; construction and delivery of a theoretically and empirically based intervention that successfully engages disadvantaged men; potential for the intervention to influence binge drinking.ResultsThe focus group analyses identified that personal experience and knowledge of the harmful effects of alcohol was widespread. Furthermore, there was a discrepancy between frequent binge drinking and perceived social expectations and duties. This could usefully be targeted in the intervention. Theoretically and empirically based behaviour change strategies were successfully rendered in attractive, colourful, brief text messages. Both recruitment strategies (GP registers and community outreach) proved successful and a total of 67 men were recruited, exceeding the target of 60. The participants were at high risk of harm because of frequent episodes of heavy binge drinking. Baseline interviews established that those recruited through community outreach drank substantially more and had more frequent binge drinking sessions than those recruited through GP registers. Retention at follow-up was 96%. Extensive process evaluation was conducted. The evaluation showed that 95% of text messages were successfully delivered to participants' telephones. Furthermore, there was a high level of engagement with text messages which sought responses. Most men replied to these texts, often giving carefully structured personal responses. Analyses of the responses indicated a high level of engagement with key components of the behaviour change strategy. Post-trial evaluation showed high levels of satisfaction with the intervention.ConclusionsThis study has shown that disadvantaged men can be recruited and retained in an alcohol intervention trial. A theoretically and empirically based intervention was successfully delivered by text message. Furthermore, the messages were well received and elicited the types of response intended. A full trial of the intervention, incorporating a cost-effectiveness study, should be carried out.Study registrationThis study is registered as ISRCTN10515845.FundingThe National Institute for Health Research Public Health Research programme.

This audit study took place in ten outpatient pain clinics and focused on the management of low back pain and nerve-damage pain. The objective was to identify and promote appropriate changes in management. An analysis of the treatment of 1236 patients with low back pain and/or nerve-damage pain highlighted wide variations in practice. Presentation of these data to the clinics was used as a means of promoting change. Data on a further 1791 patients were used to assess the extent of any changes in practice. Prior to the audit feedback, treatments were used often in some clinics, but only rarely in other clinics, for seemingly similar patients. During the feedback sessions three treatments were identified for more frequent use by several of the clinics: antidepressant and anticonvulsant drugs, and transcutaneous electrical nerve stimulation. Many changes in practice occurred after the audit intervention, with large increases in the utilisation of these three treatments. Since there is reasonable evidence to support the use of these treatments for chronic pain this represents an improvement in the process of care. The audit demonstrated that patient management can be improved by a combination of active feedback and discussions based around comparisons between centres.

Three hundred and seven valid non-users and 307 matched users of cervical screening were interviewed about who they would prefer to take the smear test, where it was carried out and at what time. Fifty-five per cent of non-users and 48 per cent of users had no preference as to whether the smear taker was a doctor or nurse but these previously unscreened women who did state a preference preferred a nurse. A female smear- taker was preferred by most non-users (77 per cent) and most users (60 per cent), the stronger preferences among non-users being statistically sig nificant (χ2 = 20.9, p < 0.0001). Only 2 per cent of non-users and 7 per cent of users specifically wanted a male to do the test while the remainder had no preference. Familiarity with the smear-taker was a more divided issue with 40 per cent of non-users and 42 per cent of users having no preference as to whether they knew the tester or not. The most popular place to have the test carried out was the GP surgery or health centre for all women. However, a minority of both groups requested a hospital well-woman or domiciliary service. There was little demand for a workplace service or weekend clinics from either group but 15 per cent of all women who wanted to attend on a weekday wanted an evening service. Preferences for smear-taker and location were not associated with age, social class or marital status. Service providers must take into account the needs of all women if they are to provide a service which will be suited to those women they want to use it. Above all, women need to know that there is a choice available if voluntary participation in the screening programme is to be encouraged.

A random sample of women (N = 614) was interviewed following a campaign to encourage uptake of cervical screening. Previously non-screened women were sent leaflets explaining the purpose of cervical screening together with up to three invitation letters to encourage attendance. Following the campaign, socio-demographic characteristics of women remaining unscreened were compared with those of the screened population to assess the role of service provision in ameliorating differences in uptake. A small social class differential existed after the call programme. The study tested the utility of cognitions specified by the Health Belief Model to distinguish participants versus non-participants and to mediate the effects of marital status, social class and sexual experience in screening uptake. Overall, health beliefs, socio-demographic variables and number of sexual partners accounted for 57 per cent of variance in screening uptake. Screened women reported greater sexual experience and the effects of sexual experience on screening uptake were mediated by perceived susceptibility, perceived costs, perceived benefits and normative belief. The effects of social class on screening uptake were mediated by perceived susceptibility, perceived aversiveness of the test procedure and perceived aversiveness of a positive result, suggesting persistent cultural barriers to uptake. No evidence was found to suggest that practical difficulties in attendance contributed to socio-demographic differentials. These findings suggest that where repeated opportunities for screening are provided by the health service, health beliefs are sufficient to identify those who take up screening. © 1996 The British Psychological Society.

BackgroundProcess evaluation is essential in developing, piloting and evaluating complex interventions. This often involves observation of intervention delivery and interviews with study participants. Mobile telephone interventions involve no face to face contact, making conventional process evaluation difficult. This study assesses the utility of novel techniques for process evaluation involving no face to face contact.MethodsText messages were delivered to 34 disadvantaged men as part of a feasibility study of a brief alcohol intervention. Process evaluation focused on delivery of the text messages and responses received from study participants. The computerized delivery system captured data on receipt of the messages. The text messages, delivered over 28 days, included nine which asked questions. Responses to these questions served as one technique for process evaluation by ascertaining the nature of engagement with the study and with steps on the causal chain to behavior change.ResultsA total of 646 SMS text messages were sent to participants. Of these, 613 messages (95%) were recorded as delivered to participants' telephones. 88% of participants responded to messages that asked questions. There was little attenuation in responses to the questions across the intervention period. Content analysis of the responses revealed that participants engaged with text messages, thought deeply about their content and provided carefully considered personal responses to the questions.ConclusionsSocially disadvantaged men, a hard to reach population, engaged in a meaningful way over a sustained period with an interactive intervention delivered by text message. The novel process measures used in the study are unobtrusive, low cost and collect real-time data on all participants. They assessed the fidelity of delivery of the intervention and monitored retention in the study. They measured levels of engagement and identified participants' reactions to components of the intervention. These methods provide a valuable addition to conventional process evaluation techniques.

The objective of this study was to compare the cost effectiveness of amoxicillin/clavulanic acid with other antibacterial regimens for prophylaxis of infection after elective abdominal or gynaecological surgery. Data from 21 previously published comparative clinical trials were used to calculate statistical confidence intervals for differences in postoperative wound infection rate. A simple model was used to produce a tabular sensitivity analysis of cost effectiveness over a wide range of costs of wound infection and potential differences in efficacy. For more expensive comparator regimens, including combination regimens utilising gentamicin and metronidazole, amoxicillin/clavulanic acid was either likely to be more cost effective or equally cost effective. For example, in trials of colonic surgery the comparators were on average 11.39 pounds more expensive than amoxicillin/clavulanic acid, which was > 95% likely to be more cost effective unless the cost of wound infection was estimated to be > 1519 pounds. Amoxicillin/clavulanic acid was more expensive than only 2 of the 21 comparators. Furthermore, in one of these 2 trials it was also significantly more effective than the comparator. In this trial, amoxicillin/clavulanic acid was > 95% likely to be more cost effective as prophylaxis in hysterectomy than rectal metronidazole, provided that the cost of wound infection was estimated to be > 179 pounds. In conclusion, this analysis shows that amoxicillin/clavulanic acid, given as monotherapy, is likely to be equally or more cost effective than a wide range of comparator regimens for prophylaxis of elective abdominal or gynaecological surgery.

190 During Sierra Leone’s violent decade-long war, the warring parties used amputation, especially of arms, as a means of terror. In a camp for amputees in the capital city Freetown, Medecins Sans Frontieres established a clinic and a treatment programme for neuropathic pain. Insecurity and cultural and language barriers have complicated this work, but medical and humanitarian benefits have been demonstrated. Pain services are virtually non-existent in less-developed countries. There have recently been no major treatment advances for neuropathic or phantom pain; however, the general body of knowledge about amputation pain can be increased by observations from these difficult settings.

OBJECTIVE--To investigate the numbers of visits required to obtain interviews with users and non-users of cervical screening, and to determine the workload involved to enable an optimum visit plan to be developed. DESIGN--Case-control study of users and non-users of cervical screening using a flexible visit plan that involved up to eight attempts at contact. Visits were made in mornings, afternoons, and evenings, the visit pattern being determined by information gained from local sources. PATIENTS--Altogether 660 non-users of cervical screening (cases), aged 20-64 and registered with 23 randomly selected general practitioners (GPs), were identified from the Tayside computerised register of cervical smears. These women were selected from the computerised lists of 18 GPs in Dundee and five in Perth. A total of 417 women recorded as having a smear within the previous three years (controls), matched by age and GP, were also identified from the computerised register. RESULTS--Altogether 1834 attempts were made to contact the cases, of whom 339 were interviewed, giving a workload of 18 interviews per 100 attempts. For the controls 1359 attempts were made at contact to yield 339 interviews, a workload of 25 interviews per 100 attempts. Refusals (19%) and incorrect addresses (23%) were the two major reasons for failing to achieve interview. Only for four (0.6%) of the cases and one (0.2%) of the controls was no information gained. The proportion of attempts which led to interview remained constant with increasing numbers of call-backs (up to six for the cases and eight for the controls). CONCLUSIONS--A flexible approach to visit scheduling that takes account of local knowledge can lead to interviews with 66% of non-users of health screening, when incorrect addresses are removed. It is preferable to plan for many (up to six) visits to achieve interview. This will minimise non-response bias without increasing the workload per successful interview.