City-based action to reduce harmful alcohol use: review of reviews

Examining How Dosage of Intervention Components from the Sacramento Neighborhood Alcohol Prevention Project Affect Child Abuse and Neglect

Alcohol environmental intervention efforts have shown mixed results in reducing child abuse and neglect. In this study, we examine how the dosage of specific intervention components of the Sacramento Neighborhood Alcohol Prevention Project (SNAPP) may differentially affect child abuse outcomes. SNAPP used a quasi-experimental phased intervention design to reduce alcohol-related problems among 15-29-year-olds in two economically, racially, and ethnically diverse neighborhoods in Sacramento, California. Study activities were conducted from 1999 through 2003. The intervention occurred in 37 Census block groups (21 block groups in the South and 16 in the North) compared to 289 block groups in the At-Large comparison area. Our child abuse outcomes include substantiations of child abuse and neglect and total and alcohol-related foster care entries. Data on child abuse outcomes were obtained from the Sacramento County Department of Children and Family Services and analyzed using conditionally autoregressive spatio-temporal Bayesian analyses. Enforcement of intoxicated patron and on-premise alcohol outlet compliance checks were related to large reductions in all three outcomes in the North intervention area, 33.4% for substantiations, 44.8% for total foster care entries, and 68.4% for alcohol-related foster care entries. However, these activities were not implemented in the South area. Community awareness activities appear to increase total and alcohol-related foster care entries in the South, but reduce substantiations and total foster care entries in the North. Compliance of on-premise outlets may be an effective intervention component to reduce child abuse and neglect; however, these results need replication. Further, despite the dosage of intervention components that reduced substantiations, the overall effect of the SNAPP intervention did not reduce this outcome.

Effects of the Sacramento Neighborhood Alcohol Prevention Project on rates of child abuse and neglect 7 years post-implementation (1999-2010)

INTRODUCTION

Evaluations of alcohol environmental prevention efforts examine short-term effects of these interventions on alcohol-related problems. We examine whether the effects of the Sacramento Neighborhood Alcohol Prevention Project (SNAPP), an alcohol environmental intervention aimed to reduce alcohol-related problems in two neighbourhoods, on child abuse and neglect remained 7 years post-implementation.

METHODS

SNAPP used a quasi-experimental non-equivalent control group design, where intervention activities occurred in the South area, followed by those in the North area 2 years later. Our sample size is 3912 space-time units (326 census block groups × 12 years [1999-2010]). Outcomes were measured at the household level and included: (i) all foster care entries total; and (ii) the subset of foster care entries that were alcohol related. Data were analysed using Bayesian conditionally autoregressive space-time models.

RESULTS

We find that the decreases in total (relative rate [RR] = 0.882, 95% credible interval [CrI] 0.795, 0.980) and alcohol-related (RR = 0.888, 95% CrI 0.791, 0.997) foster care entries remain in the North intervention area although the magnitude of those changes are smaller than immediately post-intervention. Increases found in alcohol-related foster care entries in the South area immediately post-intervention were not significant 7 years later (RR = 1.128, 95% CrI 0.975, 1.307).

DISCUSSION AND CONCLUSIONS

Reductions in child abuse and neglect due to an alcohol environmental intervention can be maintained. Environmental interventions that provide community-level primary prevention strategies could be more easily sustained and more cost effective than individual-level interventions, although more research is needed to identify why interventions may be successful in specific contexts and not others.

Assessing the effects of the Sacramento Neighborhood Alcohol Prevention Project (SNAPP) on child abuse and neglect

BACKGROUND

The role of alcohol use in the etiology of abusive and neglectful parenting is significant. We examined how the Sacramento Neighborhood Alcohol Prevention Project (SNAPP) may have reduced rates of substantiated child maltreatment, entries into foster care, and entries into foster care where alcohol use was a factor.

PARTICIPANTS AND SETTING

The study sample is 326 Census block groups: 21 and 16 in the South and North intervention areas, respectively, and 289 in the At-Large comparison area in Sacramento, California.

METHODS

SNAPP used a quasi-experimental design to reduce alcohol supply and alcohol-related problems among 15-29 year olds in two economically, racially, and ethnically diverse neighborhoods. The dependent variables are substantiated child abuse and neglect; total foster care entries; and alcohol-related foster care entries.

RESULTS

Substantiated child abuse and neglect was inconclusive for both intervention areas. In the North, total (RR = 0.822, 95 % CI [0.721, 0.933]) and alcohol-related (RR = 0.760, 95 % CI [0.634, 0.914]) foster care entries decreased by 17.8 % and 24.0 %, respectively. Intervention effects in the South were not well-supported for foster care entries (RR = 1.118, 95 % CI [0.988, 1.258]), but increased alcohol-related foster care entries (RR = 1.264, 95 % CI [1.075, 1.484]).

CONCLUSIONS

Environmental intervention strategies may be effective at reducing child abuse and neglect. However, given the mixed findings from our work, we need to identify under what conditions these interventions work best and whether some components of these strategies (e.g. awareness vs. enforcement of underage sales) differentially affect child abuse and neglect.

Levelling up health: A practical, evidence-based framework for reducing health inequalities

There are substantial inequalities in health across society which have been exacerbated by the COVID-19 pandemic. The UK government have committed to a programme of levelling-up to address geographical inequalities. Here we undertake rapid review of the evidence base on interventions to reduce such health inequalities and developed a practical, evidence-based framework to 'level up' health across the country. This paper overviews a rapid review undertaken to develop a framework of guiding principles to guide policy. To that end and based on an initial theory, we searched one electrotonic database (MEDLINE) from 2007 to July 2021 to identify published umbrella reviews and undertook an internet search to identify relevant systematic reviews, primary studies, and grey literature. Titles and abstracts were screened according to the eligibility criteria. Key themes were extracted from the included studies and synthesised into an overarching framework of guiding principles in consultation with an expert panel. Included studies were cross checked with the initial theoretical domains and further searching undertaken to fill any gaps. We identified 16 published umbrella reviews (covering 667 individual studies), 19 grey literature publications, and 15 key systematic reviews or primary studies. Based on these studies, we develop a framework applicable at national, regional and local level which consisted of five principles - 1) healthy-by-default and easy to use initiatives; 2) long-term, multi-sector action; 3) locally designed focus; 4) targeting disadvantaged communities; and 5) matching of resources to need. Decision-makers working on policies to level up health should be guided by these five principles.

Evaluation of a Community Intervention to Reduce Harmful Alcohol Consumption among Adult Population: A Study Protocol

Harmful alcohol consumption is shaped by a complex range of structural, social, and individual determinants that interact with inequality axes, which can be addressed at the community level. Under the framework of Barcelona Health in the Neighborhoods, which is a community strategy to reduce health inequalities in Barcelona’s most deprived neighborhoods, a community steering group will co-design a multicomponent community intervention. Aims: to assess its effects on: (1) alcohol accessibility, availability, and consumption at the environmental level, and (2) psychosocial and cognitive determinants of harmful alcohol consumption at the individual level. Methods: Quasi-experimental design with a comparison group, and pre- and post-intervention measures. Three Barcelona neighborhoods will be assigned to the intervention or comparison group based on three criteria: healthcare data on alcohol use, socioeconomic characteristics, and population size. The intervention includes activities promoting community mobilization, law enforcement, and communication campaigns in the intervened neighborhoods. Non-participant observations in standardized census sections will be performed in public spaces to collect information on three outcomes: alcohol accessibility, availability, and signs of alcohol consumption. Data collection includes a survey to a sample of 622 subjects to detect differences on these outcomes: risk awareness, knowledge, and self-efficacy about harmful alcohol consumption and drinking patterns. Discussion: This protocol to assess the effects of a multicomponent community intervention on harmful alcohol consumption at the environmental and population level will provide evidence on effective community health interventions and enable informed decisions for policy makers. This protocol could also be used as an implementation guide for studies aimed at reducing harmful drinking in cities with similar characteristics.

The alcohol prevention magnitude measure: Application of a Spanish-language version in Santiago, Chile

BACKGROUND

The Alcohol Prevention Magnitude Measure (APMM) is an instrument to monitor and improve substance use prevention at the community level developed in Sweden. The aim of this study was to produce and apply a Spanish-language version of the APMM.

METHOD

We translated and adapted the APMM using an expert panel. We retained 37 indicators in five dimensions, with total scores ranging from 0 to 100 points and 0 to 20 in each dimension. The instrument was administered to the prevention coordinators in six socioeconomically heterogeneous municipalities of Santiago de Chile, during the pilot implementation of a community-based prevention model in 2019 and 2020. We calculated median scores for the instrument and each dimension. We tested for differences between 2019 and 2020 using the Wilcoxon Test and between municipalities with the Friedman Test.

RESULTS

The Spanish version of the APMM was acceptable to stakeholders. The median scores were 49.3 (range: 34.0 to 64.0) in 2019 and 67.3 (range 55.5 to 80.5) in 2020. The median scores for Staff and budget were 14.0 in 2019 and 2020, for Prevention policy 5.0 in 2019 and 16.0 in 2020, for Cooperation with key agents 12.0 in both years, for Supervision and alcohol licenses 4.3 in 2019 and 9.0 in 2020, and for Prevention activities 11.0 in 2019 and 15.0 in 2020. The scores in the dimensions Prevention policy and Supervision and alcohol licenses significantly increased in 2020. The differences between the municipalities were not significant.

CONCLUSIONS

Improvements of the prevention index between 2019 and 2020 in the dimension Prevention policies may be related to the intervention. Improvements in Supervision and alcohol licenses could be related to curfew policies in the context of the COVID-19 pandemic. The Spanish version of the APMM deserves larger scale testing in Latin America.

How effects on health equity are assessed in systematic reviews of interventions

BACKGROUND

Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness.

SEARCH METHODS

We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies.

SELECTION CRITERIA

We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility.

AUTHORS' CONCLUSIONS

There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Reducing the health risks derived from exposure to addictive substances

PURPOSE OF REVIEW

To discuss the health risks due to exposure to alcohol, illegal drugs and nicotine and how these risks might be reduced.

RECENT FINDINGS

In 2016, worldwide, alcohol, illegal drugs and nicotine were responsible for some 10 million deaths. There is evolutionary and biological evidence that humans are predisposed to consuming alcohol, illegal drugs and nicotine - present-day problems are caused by high levels of potency, exposure and drug delivery systems. The two priority substances for action are alcohol and smoked cigarettes; their exposure can be reduced by price increases, setting minimum prices per product, regulating a shift form smoked cigarettes to electronic nicotine delivery devices and, theoretically, reducing the ethanol content of existing beverages. Legalization of cannabis requires a strict regulatory framework.

SUMMARY

Purposeful policy can reduce the harm done by alcohol, illegal drugs and nicotine. In particular, policy to reduce exposure to alcohol requires considerable strengthening.