Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions

BACKGROUND

People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours.

METHODS AND FINDINGS

From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use.

CONCLUSION

This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.

Factors influencing implementation and sustainability of interventions to improve oral health and related health behaviours in adults experiencing severe and multiple disadvantage: a mixed-methods systematic review

OBJECTIVES

Among people experiencing severe and multiple disadvantage (SMD), poor oral health is common and linked to smoking, substance use and high sugar intake. Studies have explored interventions addressing oral health and related behaviours; however, factors related to the implementation of these interventions remain unclear. This mixed-methods systematic review aimed to synthesise evidence on the implementation and sustainability of interventions to improve oral health and related health behaviours among adults experiencing SMD.

METHODS

Bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature were searched from inception to February 2023. Studies meeting the inclusion criteria were screened and extracted independently by two researchers. Quality appraisal was undertaken, and results were synthesised using narrative and thematic analyses.

RESULTS

Seventeen papers were included (published between 1995 and 2022). Studies were mostly of moderate quality and included views from SMD groups and service providers. From the qualitative synthesis, most findings were related to aspects such as trust, resources and motivation levels of SMD groups and service providers. None of the studies reported on diet and none included repeated offending (one of the aspects of SMD). From the quantitative synthesis, no difference was observed in programme attendance between the interventions and usual care, although there was some indication of sustained improvements in participation in the intervention group.

CONCLUSION

This review provides some evidence that trust, adequate resources and motivation levels are potentially important in implementing interventions to improve oral health and substance use among SMD groups. Further research is needed from high quality studies and focusing on diet in this population.

PROSPERO REGISTRATION NUMBER

CRD42020202416.

How co-locating public mental health interventions in community settings impacts mental health and health inequalities: a multi-site realist evaluation

BACKGROUND

Public mental health interventions are non-clinical services that aim to promote wellbeing and prevent mental ill health at the population level. In England, the health, social and community system is characterised by complex and fragmented inter-sectoral relationships. To overcome this, there has been an expansion in co-locating public mental health services within clinical settings, the focus of prior research. This study evaluates how co-location in community-based settings can support adult mental health and reduce health inequalities.

METHODS

A qualitative multi-site case study design using a realist evaluation approach was employed. Data collection took place in three phases: theory gleaning, parallel testing and refining of theories, and theory consolidation. We collected data from service users (n = 32), service providers (n = 32), funders, commissioners, and policy makers (n = 11), and members of the public (n = 10). We conducted in-depth interviews (n = 65) and four focus group discussions (n = 20) at six case study sites across England, UK, and two online multi-stakeholder workshops (n = 20). Interview guides followed realist-informed open-ended questions, adapted for each phase. The realist analysis used an iterative, inductive, and deductive data analysis approach to identify the underlying mechanisms for how community co-location affects public mental health outcomes, who this works best for, and understand the contexts in which co-location operates.

RESULTS

Five overarching co-location theories were elicited and supported. Co-located services: (1) improved provision of holistic and person-centred support; (2) reduced stigma by creating non-judgemental environments that were not associated with clinical or mental health services; (3) delivered services in psychologically safe environments by creating a culture of empathy, friendliness and trust where people felt they were being treated with dignity and respect; (4) helped to overcome barriers to accessibility by making service access less costly and more time efficient, and (5) enhance the sustainability of services through better pooling of resources.

CONCLUSION

Co-locating public mental health services within communities impacts multiple social determinants of poor mental health. It has a role in reducing mental health inequalities by helping those least likely to access services. Operating practices that engender inter-service trust and resource-sharing are likely to support sustainability.

A Systematic Review of Qualitative Studies Exploring Lived Experiences, Perceived Impact, and Coping Strategies of Children and Young People Whose Parents Use Substances

Parental substance use is highly prevalent worldwide, presenting major child safeguarding and public health concerns. Qualitative research enables in-depth understanding of how young people experience parental substance use and helps inform practice and policy through illustrative cases of experiences. This review aimed to synthesize published qualitative evidence exploring the lived experiences, perceived impact, and coping strategies of children and young people whose parents use substances. International literature databases including Medline, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, International Bibliography of the Social Sciences, Social Science Database, Sociology Collection, and Scopus were searched from inception to 2022, alongside grey literature searching and relevant websites. Qualitative accounts were included, provided by participants aged below 25 years. No language, date, or geographical limits were applied. A thematic synthesis of 35 studies, across 49 papers, covering over 700 children and young people's voices, identified five overarching themes. These themes included, (a) living with the unpredictable: insecurity within the family; (b) social and emotional impact of parental substance use; (c) controlling the uncontrollable: creating safety within the family; (d) coping with and resisting the emotional and social impacts; and (e) formal and informal support. The findings emphasize that children and young people who experience parental substance use are trying to manage and mitigate vulnerabilities and be resilient to unpredictable, adverse, and often stigmatizing experiences, usually without formal support in place. Further research is needed to coproduce child-centered interventions that promote children and young people's social and emotional resilience.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness

BACKGROUND

Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD.

METHODS

For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416.

FINDINGS

The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions.

INTERPRETATION

This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes.

FUNDING

National Institute for Health and Care Research (NIHR) Policy Research Programme.

International evidence on lived experiences of trauma during homelessness and effects on mental health including substance use: a co-produced qualitative systematic review

BACKGROUND

Trauma is an experience (physical or emotional) that is life-threatening, harmful, or out of the ordinary and has lasting effects on mental health and wellbeing. Much of the information about trauma within homeless populations focuses on events in childhood. Using coproduction principles, we aimed to synthesise qualitative evidence exploring the impact of trauma during adulthood homelessness on mental health, including substance use.

METHODS

In this qualitative systematic review, we searched ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus, and Web of Science for studies published from inception until Sept 6, 2022, alongside grey literature from relevant websites. Search terms were developed based on the PICO framework. No language, date, or geographical limits were applied. Any qualitative research reporting experiences of trauma and its impact on mental health during homelessness in adults was eligible. We extracted relevant data (eg, methodology, sample characteristics, homelessness, and findings). People with lived experience of homelessness were provided with bespoke training by the lead researcher. They contributed to refining the review aims, screening, coding, and theme development. Quality was assessed using the CASP Qualitative Studies Checklist.

FINDINGS

We included 26 qualitative papers, including 876 adults experiencing homelessness between ages 18 and 70 years (448 [51%] women and 428 [49%] men). All papers focused on urban settings. Eight papers were from the USA, five from Canada, four from the UK and Australia, three from Brazil, and one from Ethiopia and Iran. A framework synthesis of these 26 papers identified three preliminary themes. People experiencing homelessness make sense of trauma in three ways: internalised understanding, relationality to others, and with a survival lens. Coping strategies for managing feelings of fear, anxiety, and depression included substance use, self-rationalisation, and strategies to feel safe. Finally, when people experienced repeated trauma, they became either dissociated, and accepted their situation, or resilient, wishing to change their circumstances.

INTERPRETATION

Further evidence is needed in rural or coastal regions, where people experiencing homelessness may face greater isolation. Trauma rarely takes place in isolation, and often previous experiences of trauma shape how people experiencing homelessness make sense of trauma and cope with it. Support to address coping with the effects of trauma should focus on ensuring people do not become desensitised and prevent deterioration of mental health and substance use. The strength of this review is its coproduction with people with lived experience. Single person data extraction with secondary checks was a limitation.

FUNDING

National Institute for Health and Care Research (NIHR) School for Primary Care Research as part of the Three NIHR Research Schools Mental Health Programme.

Investigating social deprivation and comorbid mental health diagnosis as predictors of treatment access among patients with an opioid use disorder using substance use services: a prospective cohort study

BACKGROUND

Opioid use is a major public health concern across the globe. Opioid use and subsequent access to care is often shaped by co-occurring issues faced by people using opioids, such as deprivation, mental ill-health, and other forms of substance use. We investigated the role of social deprivation and comorbid mental health diagnoses in predicting re-engagement with substance use services or contact with crisis and inpatient services for individuals with opioid use disorder in secondary mental health care in inner-city London.

METHODS

We conducted a prospective cohort study which followed individuals diagnosed with a first episode of opioid use disorder who accessed substance use services between September 2015 and May 2020 for up to 12 months, using anonymised electronic health records. We employed negative binominal regression and Cox proportional survival analyses to assess associations between exposures and outcomes.

RESULTS

Comorbid mental health diagnoses were associated with higher contact rates with crisis/inpatient services among people with opioid use disorder: incidence rate ratios (IRR) and 95% confidence intervals (CI) were 3.91 (1.74-9.14) for non-opioid substance use comorbidity, 8.92 (1.81-64.4) for a single comorbid mental health diagnosis, and 15.9 (5.89-47.5) for multiple comorbid mental health diagnoses. Social deprivation was not associated with contact rates with crisis/inpatient services within this sample. Similar patterns were found with time to first crisis/inpatient contact. Social deprivation and comorbid mental health diagnoses were not associated with re-engagement with substance use services.

CONCLUSION

Comorbid substance and mental health difficulties amongst people with an opioid use disorder led to earlier and more frequent contact with crisis/inpatient mental health services during the first 12 months of follow up. Given the common co-occurrence of mental health and substance use disorders among those who use opioids, a better understanding of their wider needs (such as social, financial and other non-medical concerns) will ensure they are supported in their treatment journeys.

A realist approach to understanding alliancing within Local Government public health and social care service provision

BACKGROUND

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

METHODS

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

RESULTS

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

CONCLUSIONS

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Impact of School and Peer Connectedness on Adolescent Mental Health and Well-Being Outcomes during the COVID-19 Pandemic: A Longitudinal Panel Survey

School closures and social distancing measures during the pandemic have disrupted young people’s daily routines and social relationships. We explored patterns of change in adolescent mental health and tested the relationship between pre-pandemic levels of school and peer connectedness and changes in mental health and well-being between the first lockdown and the return to school. This is a secondary analysis of a longitudinal 3-wave panel survey. The study sample included 603 students (aged 13–14) in 17 secondary schools across south-west England. Students completed a survey pre-pandemic (October 2019), during lockdown (May 2020) and shortly after returning to school (October 2020). Multilevel models, with random effects, were conducted for anxiety, depression and well-being outcomes with school and peer connectedness as predictor variables. Symptoms of anxiety decreased from pre-pandemic to during the first UK lockdown and increased on the return to school; anxious symptoms decreased the most for students reporting feeling least connected to school pre-pandemic. Students reporting low levels of school and peer connectedness pre-pandemic experienced poorer mental health and well-being at all time points. Low school connectedness pre-pandemic was associated with a greater increase in anxious and depressive symptoms between lockdown and the return to school when compared to students with medium levels of school connectedness. No associations were found with high school connectedness or with low/high peer connectedness. For adolescents with poor school connectedness, the enforced time away from school that the pandemic caused led to reduced anxiety. Going forwards, we need to consider ways in which to promote connection with school as a way of supporting mental health and well-being.

A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an ‘evidence for practice’ briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

“It's been up and down”—perspectives on living through COVID-19 for individuals who experience homelessness: a qualitative study

Background

The UN describes the COVID-19 pandemic as the greatest public health crisis for the current generation. However, individuals who experienced austerity, adversity, and disadvantage prior to the pandemic have been disproportionately affected with every turn the pandemic has taken, from transmission risk to vaccination take-up. One such population is individuals who experience homelessness. As the UK begins to transition to a stage of post-pandemic recovery, it is imperative to understand the perceived impact COVID-19 has had on the day-to-day lives of individuals who experience homelessness, to ensure they are not left behind and recovery planning can be better targeted to their specific needs.

Methods

Between February and May, 2021, 26 individuals (10 women and 16 men) who self-identified as experiencing homelessness within the Newcastle Gateshead area took part in telephone interviews of 20–80 min in length. Participants provided written or verbal informed consent prior to participating. Recruitment took place through existing networks, housing providers, charities, word of mouth, and snowball sampling. Analysis was co-produced with five individuals with lived experience using interpretative phenomenological analysis. NVivo release 1·5 was used to organise quotes. Ethics approval was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University's Research Ethics Committee (ref 2034/6698/2020.)

Findings

Experiences shared depicted unique stories with commonalities across the findings through five main themes: (1) surreality of day-to-day life—searching for understanding and lost autonomy; (2) an emotional rollercoaster—confronting negative emotions; (3) loneliness is my best friend—learning from being alone; (4) adversity is the only consistency—recognising past and present hardship, violence, and loss; and (5) coping with uncertainty—using drugs, mindfulness, and technology to survive.

Interpretation

The pandemic has affected the daily lives of people who experience homelessness in a variety of ways, including personal growth, no change, and regression. This study is limited by its localised recruitment in Newcastle and Gateshead in the UK; however, this local focus and involvement of individuals with lived experience has strengthened the study's implications for policy and practice in the region. Initiatives or policies developed to support post-pandemic recovery should reflect the array of impacts, while giving special recognition to loneliness, adversity, and resiliency among individuals who experience homelessness.

Funding

National Institute for Health Research School for Public Health Research.

Community interventions for improving adult mental health: mapping local policy and practice in England

BACKGROUND

Public mental health (PMH) aims to improve wellbeing and prevent poor mental health at the population level. It is a global challenge and a UK priority area for action. Communities play an important role in the provision of PMH interventions. However, the evidence base concerning community-based PMH interventions is limited, meaning it is challenging to compare service provision to need. Without this, the efficient and equitable provision of services is hindered. Here, we sought to map the current range of community-based interventions for improving mental health and wellbeing currently provided in England to inform priority areas for policy and service intervention.

METHOD

We adopted an established mapping exercise methodology, comparing service provision with demographic and deprivation statistics. Five local authority areas of England were selected based on differing demographics, mental health needs and wider challenging circumstances (i.e. high deprivation). Community-based interventions were identified through: 1) desk-based research 2) established professional networks 3) chain-referral sampling of individuals involved in local mental health promotion and prevention and 4) peer researchers' insight. We included all community-based, non-clinical interventions aimed at adult residents operating between July 2019 and May 2020.

RESULTS

407 interventions were identified across the five areas addressing 16 risk/protective factors for PMH. Interventions for social isolation and loneliness were most prevalent, most commonly through social activities and/or befriending services. The most common subpopulations targeted were older adults and people from minority ethnic backgrounds. Interventions focusing on broader structural and environmental determinants were uncommon. There was some evidence of service provision being tailored to local need, though this was inconsistent, meaning some at-risk groups such as men or LGBTQ+ people from minority ethnic backgrounds were missed. Interventions were not consistently evaluated.

CONCLUSIONS

There was evidence of partial responsiveness to national and local prioritising. Provision was geared mainly towards addressing social and individual determinants of PMH, suggesting more integration is needed to engage wider service providers and policy-makers in PMH strategy and delivery at the community level. The lack of comprehensive evaluation of services to improve PMH needs to be urgently addressed to determine the extent of their effectiveness in communities they serve.

Understanding the life experiences of people with multiple complex needs: peer research in a health needs assessment

BACKGROUND

Multiple complex needs (MCN) describe a population experiencing a combination of homelessness, substance use, offending and/or mental ill-health. Using peer researchers, this study aimed to explore the perspectives of individuals with lived experience of MCN with regards to (i) issues leading to MCN and (ii) key intervention opportunities.

METHODS

As part of a health needs assessment in Gateshead (North East England), trained peer researchers interviewed 27 adults (aged ≥18 years) with experience of MCN, identified using purposive sampling methods. Peer researchers designed a topic guide for interviews which were audio recorded and thematically analyzed.

RESULTS

Interviewees reported adverse childhood experiences leading to MCN including abuse, bereavement, parental imprisonment, family break-up and inadequate support. Mental ill-health, substance use, poverty, early experiences of unstable housing and acute homelessness were identified as major precedents for adulthood experiences of MCN. Between 16 and 20 years, access to housing, social and mental health support was perceived as having the potential to prevent circumstances worsening. Individuals perceived removing barriers to mental health, housing and welfare and financial supports could help.

CONCLUSIONS

This study highlights the perceived role austerity, adverse childhood events and current service provision have in current and future experiences of MCN. Individuals expressed a need for future interventions and support to be judgement free and provided by workers who are educated about MCN and related adversity. Involving peer researchers and individuals with experience of MCN in future research and service provision could ensure appropriate measures and supports are put in place.

Exploring high mortality rates among people with multiple and complex needs: a qualitative study using peer research methods

OBJECTIVE

To explore the perceived reasons underlying high mortality rates among people with multiple and complex needs.

DESIGN

Qualitative study using peer research.

SETTING

North East of England.

PARTICIPANTS

Three focus group discussions were held involving (1) people with lived experience of multiple and complex needs (n=5); (2) front-line staff from health, social care and voluntary organisations that support multiple and complex needs groups (n=7); and (3) managers and commissioners of these organisations (n=9).

RESULTS

Findings from this study provide valuable perspectives of people with multiple complex needs and those that provide them with support on what may be perceived factors underlying premature mortality. Mental ill health and substance misuse (often co-occurring dual diagnosis) were perceived as influencing premature mortality among multiple and complex needs groups. Perceptions of opportunities to identify people at risk included critical life events (eg, bereavement, relationship breakdown) and transitions (eg, release from prison, completion of drug treatment). Early prevention, particularly supporting young people experiencing adverse childhood experiences, was also highlighted as a priority.

CONCLUSION

High mortality in multiple and complex needs groups may be reduced by addressing dual diagnosis, providing more support at critical life events and investing in early prevention efforts. Future interventions could take into consideration the intricate nature of multiple and complex needs and improve service access and navigation.

Perceptions on the sexual harassment of female nurses in a state hospital in Sri Lanka: a qualitative study

Background: Sexual harassment occurs within the nursing profession globally, challenging the health and safety of nurses and the quality and efficiency of health systems. In Sri Lanka, no studies have explored this issue in the health sector; however, female employees face sexual harassment in other workplace settings.

Objective: To explore female nurses’ perceptions of workplace sexual harassment in a large state hospital in Sri Lanka.

Methods: This is a qualitative study conducted in an urban, mainly Buddhist and Singhalese context. We invited all female senior and ward nurses working in the hospital to participate in the study. We conducted individual in-depth interviews with four senior nurses and focus group discussions with 29 nurses in three groups.

Results: The nurses described a variety of perceived forms of sexual harassment in the hospital. They discussed patient-perpetrated incidents as the most threatening and the clearest to identify compared with incidents involving doctors and other co-workers. There was significant ambiguity regarding sexual consent and coercion in relationships between female nurses and male doctors, which were described as holding potential for exploitation or harassment. The nurses reported that typical reactions to sexual harassment were passive. Alternatively, they described encountering inaction or victim blaming when they attempted to formally report incidents. They perceived that workplace sexual harassment has contributed to negative societal attitudes about the nursing profession and discussed various informal strategies, such as working in teams, to protect themselves from sexual harassment in the hospital.

Conclusions: Sexual harassment was a perceived workplace concern for nurses in this hospital. To develop effective local prevention and intervention responses, further research is required to determine the magnitude of the problem and explore differences in responses to and consequences of sexual harassment based on perpetrator type and intent, and personal vulnerabilities of the victims, among other factors.

Urban growth and water access in sub-Saharan Africa: Progress, challenges, and emerging research directions

For the next decade, the global water crisis remains the risk of highest concern, and ranks ahead of climate change, extreme weather events, food crises and social instability. Across the globe, nearly one in ten people is without access to an improved drinking water source. Least Developed Countries (LDCs) especially in sub-Saharan Africa (SSA) are the most affected, having disproportionately more of the global population without access to clean water than other major regions. Population growth, changing lifestyles, increasing pollution and accelerating urbanization will continue to widen the gap between the demand for water and available supply especially in urban areas, and disproportionately affect informal settlements, where the majority of SSA's urban population resides. Distribution and allocation of water will be affected by climate-induced water stresses, poor institutions, ineffective governance, and weak political will to address scarcity and mediate uncertainties in future supply. While attempts have been made by many scientists to examine different dimensions of water scarcity and urban population dynamics, there are few comprehensive reviews, especially focused on the particular situation in Sub-Saharan Africa. This paper contributes to interdisciplinary understanding of urban water supply by distilling and integrating relevant empirical knowledge on urban dynamics and water issues in SSA, focusing on progress made and associated challenges. It then points out future research directions including the need to understand how alternatives to centralized water policies may help deliver sustainable water supply to cities and informal settlements in the region.

Effect of neodymium: YAG laser on sodium hyaluronate in vitro as a model for postcapsulotomy intraocular pressure change

PURPOSE

To define one possible etiology for the rise in intraocular pressure (IOP) after neodymium: YAG (Nd:YAG) laser capsulotomy and provide information for the continued investigation of this process.

SETTING

Laser Center, Eye and Ear Institute, Pittsburgh, Pennsylvania.

METHODS

Samples of 1% sodium hyaluronate or balanced salt solution (BSS) (control) were placed in a closed system and exposed to varying amounts of Nd:YAG energy delivered by a Coherent YAG laser. This system was hydrostatically coupled to a pressure monitor, and changes in pressure were recorded as a function of time.

RESULTS

Average pressure increase was 0.140 mm Hg/mJ of YAG energy in the sodium hyaluronate samples and 0.017 mm Hg/mJ in BSS (P < .01). The relationship between total energy delivered and maximum pressure recorded for both substances was nearly linear. Further analysis of treated sodium hyaluronate samples showed that Nd:YAG energy can produce structural alterations.

CONCLUSIONS

Neodymium:YAG laser energy has a pronounced effect on sodium hyaluronate that exceeds the thermal effect seen with BSS when the pressure is monitored in a closed system. These structural changes might contribute to the IOP rise seen clinically.

Robots in food systems: a review and assessment of potential uses

Management personnel in foodservice, food processing, and robot industries were surveyed to evaluate potential job functions for robots in the food industry. The survey instrument listed 64 different food-related job functions that participants were asked to assess as appropriate or not appropriate for robotic implementation. Demographic data were collected from each participant to determine any positive or negative influence on job function responses. The survey responses were statistically evaluated using frequencies and the chi-square test of significance. Sixteen of the 64 job functions were identified as appropriate for robot implementation in food industries by both robot manufacturing and food managers. The study indicated, first, that food managers lack knowledge about robots and robot manufacturing managers lack knowledge about food industries. Second, robots are not currently being used to any extent in the food industry. Third, analysis of the demographic data in relation to the 16 identified job functions showed no significant differences in responses.

Metabolites of phenanthridine formed by rat liver homogenate

The ethyl acetate-extractable metabolites of phenanthridine as formed in vitro with Aroclor-induced rat liver homogenate were isolated and structurally identified. The relative amounts of these metabolites were determined using [6-14C]phenanthridine. The major metabolites of phenanthridine formed under these incubation conditions were identified as phenanthridine-N-oxide, 1,2-dihydroxy-1,2-dihydrophenanthridine, and 9,10-dihydroxy-9,10-dihydrophenanthridine. Phenanthridone and 2-hydroxyphenanthridine were identified as minor metabolites. These data were obtained using an identical incubation mixture as employed in mutagenicity assays. It is suggested that metabolites in addition to phenanthridone are likely to contribute to mutagenicity of phenanthridine observed in assays performed with metabolic activation.

Tumor-initiating activity of quinoline and methylated quinolines on the skin of SENCAR mice

Quinoline and all 7 positional isomers of methylquinoline were assayed for tumor-initiating activity on the skin of SENCAR female mice with promotion by tetradecanoyl phorbol acetate. The total initiation dose of either quinoline or the isomeric methylquinolines was 7.5 mg per mouse. Quinoline induced tumors in 53% of the mice (0.73 tumors per animal). While 2-, 3-, 5- and 7-methylquinoline did not exhibit significant tumorigenic activity in this assay, 4-methylquinoline induced tumors in 45% of the mice (0.90 tumors per animal). 8-Methylquinoline induced tumors in 45% of the mice (0.66 tumors per animal).

On the metabolism of quinoline and isoquinoline: possible molecular basis for differences in biological activities

Quinoline is a hepatocarcinogen in mice and rats, a mutagen in Salmonella typhimurium, and induces unscheduled DNA synthesis in primary cultures of rat hepatocytes. In contrast, isoquinoline has not been shown to be genotoxic. The metabolites of quinoline and isoquinoline, as formed in vitro with rat liver homogenate, were identified to investigate possible molecular bases for the differences in their biological activity. The ethyl acetate extractable metabolites of quinoline and isoquinoline were analyzed directly by high pressure liquid chromatography and, after silylation, by capillary gas chromatography. The major metabolite of quinoline was 5,6-dihydroxy-5,6-dihydroquinoline. Lesser amounts of 2- and 3-hydroxyquinoline and quinoline-N-oxide were also identified as metabolites. 1-, 4- and 5-Hydroxyiso-quinoline and isoquinoline-N-oxide were detected as metabolites of isoquinoline. 5,6-Dihydroxy-5,6-dihydroiso-quinoline was detected as only a minor metabolite. This difference in the extent to which these isomers are ultimately metabolized to dihydrodiols may be associated with their differences in biological activity. Quinoline, 4-methylquinoline and 7-methylquinoline were bioassayed as tumor initiators on the skin of Sencar mice. While 4-methylquinoline was at least as potent a tumor initiator as quinoline, 7-methylquinoline was not significantly tumorigenic in this assay. These data are consistent with the hypothesis that formation of the 5,6-epoxide of quinoline is associated with its metabolic activation to a tumorigen.

Identification of the metabolites of benzo[f]quinoline and benzo[h]quinoline formed by rat liver homogenate

Benzo[f]quinoline and benzo[h]quinoline are widespread environmental pollutants which have been found to be mutagenic. The metabolism of benzo[f]quinoline and benzo[h]quinoline was investigated using a liver homogenate from Aroclor-pretreated rats. The metabolites of benzo[f]quinoline which were identified were 7,8-dihydroxy-7,8-dihydrobenzo[f]quinoline, 9,10-dihydroxy-9,10-dihydrobenzo[f]quinoline, 7-hydroxybenzo[f]quinoline, and benzo[f]quinoline-N-oxide. Metabolism studies on benzo[f]quinoline performed in the presence of the epoxide hydratase inhibitor, 3,3,3-trichloropropylene oxide, demonstrated that the formation of both of these dihydrodiols can be inhibited. The major metabolites of benzo[h]quinoline were identified as 5,6-dihydroxy-5,6-dihydrobenzo[h]quinoline and 7,8-dihydroxy-7,8-dihydrobenzo[h]quinoline. Benzo[h]quinoline-N-oxide was not detected as a metabolite. In the presence of an epoxide hydratase inhibitor, the major metabolites of benzo[h]quinoline were 5,6-epoxybenzo[h]quinoline and 7-hydroxybenzo[h]quinoline. The difference in the metabolism to N-oxides observed between benzo[h]quinoline and benzo[f]quinoline is consistent with previous observations in which sterically hindered aromatic ring nitrogen compounds such as benzo[h]quinoline are more resistant to N-oxide formation. The nitrogen atom of these aza-arenes with its lone pair of electrons has a significant influence on sites at which dihydrodiols are formed. The data suggest that the aromatic ring nitrogen of these azaphenanthrenes has an effect similar to that of a methyl substituent in directing their metabolic oxidation.

Chromosome polymorphism and banding patterns in the owl monkey (Aotus)

Diploid numbers, chromosome morphology, G- and C-banding characterisitics and pelage phenotypes were studied in 330 owl monkeys (Aotus) captured and exported from several parts of South America. Among these animals, seven distinctive karyotypes were recognized by the number of chromosomes and their individual identification by G- and C-banding methods. These seven karyotypes were distributed among four distinctive phenotypes differentiated by color patterns in the pelage. These specific phenotypes were designated in this study with capital letters (A through D) and the karyotypes by Roman numerals (I-VII), followed in parentheses by their diploid number. Specimens with phenotype A originated from Brazil and their karyotypes all conformed to a type designated karyotype I (2n=54). Animals classified as having phenotype B were exported from Colombia and their karyotypes were designated as karyotypes II (2n=54), III (2n=53), IV (2n=52), and V (2n=46). Monkeys received from Peru were designated as phenotype C and karyotype VII (2n=52). A group of owl monkeys received from Bolivia were designated as having karyotype VI (2n=50 male; 2n=49 female). Their distinctive phenotype was labeled D. All males in this sample had a diploid number of 49 and the Y-chromosome was translocated to an autosome.