Using intervention time series analyses to assess the effects of imperfectly identifiable natural events: A general method and example

BACKGROUND: Intervention time series analysis (ITSA) is an important method for analysing the effect of sudden events on time series data. ITSA methods are quasi-experimental in nature and the validity of modelling with these methods depends upon assumptions about the timing of the intervention and the response of the process to it. METHOD: This paper describes how to apply ITSA to analyse the impact of unplanned events on time series when the timing of the event is not accurately known, and so the problems of ITSA methods are magnified by uncertainty in the point of onset of the unplanned intervention. RESULTS: The methods are illustrated using the example of the Australian Heroin Shortage of 2001, which provided an opportunity to study the health and social consequences of an abrupt change in heroin availability in an environment of widespread harm reduction measures. CONCLUSION: Application of these methods enables valuable insights about the consequences of unplanned and poorly identified interventions while minimising the risk of spurious results.

If People Were Kaleidoscopes: Sharpening the Resolution on Patient Engagement in Safety

Healthcare is unacceptably error prone. The question remains why, with 20 years of evidence, is error and harm reduction not being effective? While precise numbers may be debated, all stakeholders recognize the frequency of healthcare errors is unacceptable, and greater efforts to ensure safety must occur. In recent years, one of these strategies has been the inclusion of the patient and their family as partners in safety, and has been a required organizational practice of Accreditation Canada in many of their standard sets. Existing patient advisories created to encourage engagement, have typically not included patient perspectives in their development or been comprehensively evaluated. There are no existing tools to determine if and how a patient wants to be involved in safety engagement. As such, a multi-phased study was undertaken to advance our knowledge about the client’s and family’s role in promoting safety. Phase 1 of the study was a scoping review to methodically review the existing literature about patients’ and families’ attitudes, beliefs and behaviours about their involvement in healthcare safety. Phase 2 was designed to inductively explore how a group of patients in an Ontario, Canada, community hospital, describe healthcare safety and see their role in preventing error. The study findings, which include the narratives of 30 patients and 4 family members, indicate that although there are shared themes that influence a patient’s engagement in patient safety, every individual has unique, changing beliefs, experiences and reasons for involvement. Five conceptual themes emerged from their narratives: Personal Capacity, Experiential Knowledge, Personal Character, Relationships, and Meaning of Safety. These study results will be used to develop and test a pragmatic, accessible tool to enable providers a way to collaborate with patients for determining their personal level and type of safety involvement. The most ethical and responsible approach to healthcare safety is to consider every facet and potential way for improvement. This exploratory study provides fundamental insights into the complexity of patient engagement in safety, and evidence for future steps.

E-cigarettes: an evidence update - A report commissioned by Public Health England

This review explains the relative risks and benefits of e-cigarettes, in terms of harm reduction when compared with cigarettes and as an aid to quitting.

How can geographical information systems and spatial analysis inform a response to prescription opioid misuse? a discussion in the context of existing literature

Intervenção socioeducativa: investigação-ação participativa com trabalhadoras do sexo de rua e uma equipa de outreach

Nos últimos anos, assistimos ao crescimento do conhecimento sobre o trabalho sexual e os seus atores. No entanto, poucos estudos envolvem os/as trabalhadores/as do sexo (TS) como participantes ativos. Esta tese apresenta uma pesquisa de investigação-ação participativa (IAP) composta por dois estudos que, de forma complementar, pretendem contribuir para o desenvolvimento de uma proposta socioeducativa de intervenção centrada nos direitos e necessidades dos/as TS. O estudo preliminar pretende refletir sobre os discursos institucionais produzidos em torno do trabalho sexual e dar a conhecer as práticas socioeducativas empreendidas pelas instituições que dirigem serviços a TS, em Portugal. O segundo estudo apresenta o processo e os resultados de uma IAP, com TS de rua e uma equipa de outreach. O propósito do segundo estudo consistiu em identificar as necessidades e as vontades das TS e de uma equipa de outreach, com a finalidade de encorajar os/as participantes na construção de um modelo socioeducativo de intervenção. O estudo preliminar foi efetuado junto das 23 instituições que, à data deste estudo (de outubro de 2012 a março de 2013), prestavam apoio a TS. Concluímos que os serviços são bastante similares, focados na redução de riscos decorrentes do trabalho sexual, sobretudo a nível da promoção e educação para a saúde, assumindo uma intervenção tradicional centrada na epidemiologia. De forma menos expressiva, encontrámos instituições que se centram no apoio ao abandono da atividade. Todas assumem um papel fundamental no debate social e político sobre a prostituição enquanto trabalho ou opressão. Estes resultados conduziram-nos à formulação das seguintes questões: 1) Os serviços tradicionais centrados na epidemiologia reforçam inadvertidamente o estigma do/a TS?; 2) Quais são as preocupações, necessidades e vontades reais dos/as TS?; 3) O que pensam sobre serem envolvidos/as no desenho, implementação e avaliação de projetos que lhes dizem respeito? Assim, identificámos uma falta de participação dos/as TS em projetos a si dirigidos, corroborada pela literatura científica. O segundo estudo foi desenvolvido, de setembro de 2012 a junho de 2015, através de três ciclos de planificação-ação-reflexão com TS de rua e uma equipa de outreach, em Coimbra, tendo envolvido 28 participantes formais. Através de entrevistas e da reinterpretação conjunta dos resultados das mesmas, verificámos a existência de preocupações comuns, designadamente no que se refere à saúde e segurança ocupacionais, mas pouca coesão entre as TS. As iniciativas de conscientização, desenvolvidas no âmbito da IAP, providenciaram um sentido de controlo, mas a transformação da subjetividade em ação coletiva continua a ser premente. Por tal, propomos um modelo de intervenção socioeducativa com TS, segundo uma abordagem centrada na relação e na prática reflexiva, através do recurso a métodos e à filosofia da IAP. Propomos, ainda, algumas recomendações em torno da educação/formação dos profissionais de proximidade, das/os TS e, a um nível macro, iniciativas educativas centrada na desconstrução social do género.

A rede em ação intersetorial e comunitária como espaço de formação na abordagem ao usuário de drogas

Tese (doutorado)—Universidade de Brasília, Instituto de Psicologia, Psicologia Clínica e Cultura, 2015.

Iowa State wide Strategic Plan for Healthcare Associated Infections, October 28, 2015

Iowa State wide Strategic Plan for Healthcare Associated Infections, prevention, harm reduction, community care coordination, survey and data.

El papel de la OEA en el establecimiento de los tribunales de tratamiento de drogas en Estados Unidos como mecanismo de reducción del daño (1989-2013)

La reducción de la demanda, específicamente por medios alternativos al sistema penal tradicional, ha sido uno de los componentes más discutidos en los análisis que abordan la lucha contra las drogas. Este artículo se propone determinar el papel de la Organización de Estados Americanos en el establecimiento de los Tribunales de Tratamiento de Drogas en Estados Unidos como mecanismo de reducción del daño en el periodo comprendido entre 1989 y 2013. Se sugiere que la organización internacional, a través de la CICAD, ha jugado un papel de promoción, y evaluación de los Tribunales de Tratamiento de Drogas en Estados Unidos, generando presión entre sus Estados miembro, dada la necesidad de instaurar alternativas legales de reducción del daño. Sin embargo, se presentan deficiencias en los mecanismos de evaluación, ya que las indicaciones realizadas no tienen un carácter obligatorio y por tanto las determinaciones de la CICAD no necesariamente son adoptadas.

Etapas de cambio comportamental frente al consumo de drogas ilegales, tabaco y alcohol en escolares de 9 a 17 años de Bogotá – Colombia

Objetivo: El propósito del estudio fue describir estadísticamente las etapas de cambio comportamental frente al consumo de sustancias psicoactivas –SPA– (alcohol, tabaco y drogas ilegales) en escolares entre 9 y 17 años de Bogotá- Colombia, pertenecientes al estudio FUPRECOL. Método: Se trata de un estudio descriptivo y transversal en 6.965 niños y adolescentes entre 9 y 17 años, pertenecientes a 24 instituciones educativas oficiales de Bogotá - Colombia. La medición de los procesos de cambio propuestos por el Modelo Transteórico (MTT), aplicados al consumo de drogas, tabaco y alcohol se aplicaron de manera auto-diligenciada mediante un cuestionario estructurado. Resultados: De la muestra evaluada, el 58,4% fueron mujeres con un promedio de edad 12,74 ± 2.38 años. En la población en general, frente al consumo de drogas, el 6% de los escolares se encontraban en etapa de pre-contemplación, 44 % en contemplación; 30% en preparación/acción, 20% en mantenimiento. Con relación al consumo de alcohol, el 5% de los niños y adolescentes se encontraban en etapa de pre-contemplación, 36 % en contemplación; 12% en preparación/acción, 46% en mantenimiento. Frente al tabaco, el 4% de los niños y adolescentes se encontraban en etapa de pre-contemplación, 33 % en contemplación; 12% en preparación/acción, 51% en mantenimiento. Conclusiones: En los escolares evaluados, un importante porcentaje se ubica en la etapa de mantenimiento frente a la intención de consumo de tabaco y alcohol. Frente al consumo de drogas ilegales los niños y adolescentes están en la etapa de contemplación. Se requieren esfuerzos mayores para fomentar programas preventivos que enseñen sobre el riesgo del abuso/dependencia de este tipo de sustancias psicoactiva sobre la salud; dándole prioridad en las agendas y políticas públicas dentro del ámbito escolar.

The effects of the 2004 reduction in the price of alcohol on alcohol-related harm in Finland : A natural experiment based on register data

Changes in alcohol pricing have been documented as inversely associated with changes in consumption and alcohol-related problems. Evidence of the association between price changes and health problems is nevertheless patchy and is based to a large extent on cross-sectional state-level data, or time series of such cross-sectional analyses. Natural experimental studies have been called for. There was a substantial reduction in the price of alcohol in Finland in 2004 due to a reduction in alcohol taxes of one third, on average, and the abolition of duty-free allowances for travellers from the EU. These changes in the Finnish alcohol policy could be considered a natural experiment, which offered a good opportunity to study what happens with regard to alcohol-related problems when prices go down. The present study investigated the effects of this reduction in alcohol prices on (1) alcohol-related and all-cause mortality, and mortality due to cardiovascular diseases, (2) alcohol-related morbidity in terms of hospitalisation, (3) socioeconomic differentials in alcohol-related mortality, and (4) small-area differences in interpersonal violence in the Helsinki Metropolitan area. Differential trends in alcohol-related mortality prior to the price reduction were also analysed. A variety of population-based register data was used in the study. Time-series intervention analysis modelling was applied to monthly aggregations of deaths and hospitalisation for the period 1996-2006. These and other mortality analyses were carried out for men and women aged 15 years and over. Socioeconomic differentials in alcohol-related mortality were assessed on a before/after basis, mortality being followed up in 2001-2003 (before the price reduction) and 2004-2005 (after). Alcohol-related mortality was defined in all the studies on mortality on the basis of information on both underlying and contributory causes of death. Hospitalisation related to alcohol meant that there was a reference to alcohol in the primary diagnosis. Data on interpersonal violence was gathered from 86 administrative small-areas in the Helsinki Metropolitan area and was also assessed on a before/after basis followed up in 2002-2003 and 2004-2005. The statistical methods employed to analyse these data sets included time-series analysis, and Poisson and linear regression. The results of the study indicate that alcohol-related deaths increased substantially among men aged 40-69 years and among women aged 50-69 after the price reduction when trends and seasonal variation were taken into account. The increase was mainly attributable to chronic causes, particularly liver diseases. Mortality due to cardiovascular diseases and all-cause mortality, on the other hand, decreased considerably among the-over-69-year-olds. The increase in alcohol-related mortality in absolute terms among the 30-59-year-olds was largest among the unemployed and early-age pensioners, and those with a low level of education, social class or income. The relative differences in change between the education and social class subgroups were small. The employed and those under the age of 35 did not suffer from increased alcohol-related mortality in the two years following the price reduction. The gap between the age and education groups, which was substantial in the 1980s, thus further broadened. With regard to alcohol-related hospitalisation, there was an increase in both chronic and acute causes among men under the age of 70, and among women in the 50-69-year age group when trends and seasonal variation were taken into account. Alcohol dependence and other alcohol-related mental and behavioural disorders were the largest category in both the total number of chronic hospitalisation and in the increase. There was no increase in the rate of interpersonal violence in the Helsinki Metropolitan area, and even a decrease in domestic violence. There was a significant relationship between the measures of social disadvantage on the area level and interpersonal violence, although the differences in the effects of the price reduction between the different areas were small. The findings of the present study suggest that that a reduction in alcohol prices may lead to a substantial increase in alcohol-related mortality and morbidity. However, large population group differences were observed regarding responsiveness to the price changes. In particular, the less privileged, such as the unemployed, were most sensitive. In contrast, at least in the Finnish context, the younger generations and the employed do not appear to be adversely affected, and those in the older age groups may even benefit from cheaper alcohol in terms of decreased rates of CVD mortality. The results also suggest that reductions in alcohol prices do not necessarily affect interpersonal violence. The population group differences in the effects of the price changes on alcohol-related harm should be acknowledged, and therefore the policy actions should focus on the population subgroups that are primarily responsive to the price reduction.

Population based screening - the difficulty of how to do more good than harm and how to achieve it

Screening people without symptoms of disease is an attractive idea. Screening allows early detection of disease or elevated risk of disease, and has the potential for improved treatment and reduction of mortality. The list of future screening opportunities is set to grow because of the refinement of screening techniques, the increasing frequency of degenerative and chronic diseases, and the steadily growing body of evidence on genetic predispositions for various diseases. But how should we decide on the diseases for which screening should be done and on recommendations for how it should be implemented? We use the examples of prostate cancer and genetic screening to show the importance of considering screening as an ongoing population-based intervention with beneficial and harmful effects, and not simply the use of a test. Assessing whether screening should be recommended and implemented for any named disease is therefore a multi-dimensional task in health technology assessment. There are several countries that already use established processes and criteria to assess the appropriateness of screening. We argue that the Swiss healthcare system needs a nationwide screening commission mandated to conduct appropriate evidence-based evaluation of the impact of proposed screening interventions, to issue evidence-based recommendations, and to monitor the performance of screening programmes introduced. Without explicit processes there is a danger that beneficial screening programmes could be neglected and that ineffective, and potentially harmful, screening procedures could be introduced.