Abstracts for presentation
PLENARY
Georgie MacArthur
University of Bristol
Individual-, family- and school-based interventions to prevent multiple risk behaviours in young people aged 8-25 years: a Cochrane systematic review and meta-analysis.
MacArthur GJ, NIHR Postdoctoral Research Fellow, University of Bristol
Caldwell DM,Senior Lecturer, University of Bristol
Redmore J, Medical Student, University of Aberdeen School of Medicine and Dentistry
Watkins S, PhD Student, University of Bristol
Kipping R, Senior Research Fellow, University of Bristol
White J, Senior Lecturer, Cardiff University
Chittleborough C, Senior Lecturer, University of Adelaide
Langford R, Senior Research Associate, University of Bristol
Er V, Research Associate, University of Bristol
Lingam R, Senior Clinical Lecturer, Newcastle University
Pasch K, Associate Professor, University of Texas
Gunnell DJ, Professor of Epidemiology, University of Bristol
Hickman M, Professor of Epidemiology and Public Health, University of Bristol
Campbell R, Professor of Public Health Research, University of Bristol
Aim: We aimed to undertake a Cochrane systematic review to quantify the effect of multiple risk behaviour interventions on prevention of substance use, antisocial behaviour, sexual risk, vehicle risk, self-harm, gambling, physical inactivity and unhealthy diet among individuals aged 8-25 years (CD009927)
Background: Risk behaviours that give rise to chronic diseases often emerge during adolescence, and can have substantial impacts on morbidity and mortality. Up to 24% of young people may engage in multiple behaviours, thus interventions that address multiple behaviours may provide an efficient means of prevention. However, little is known about their effectiveness and there is no quantitative estimate of effect.
Methodology: Eleven databases were searched to 14 November 2016. Randomised controlled trials were included that addressed two or more risk behaviours in individuals aged 0-18 years. Data were pooled in a random-effects meta-analysis. Certainty of evidence was assessed using GRADE.
Results: We identified 34,680 titles, screened 27,691 articles and included seventy studies. Evidence indicated that universal school-based interventions may be beneficial in preventing tobacco use (OR 0.77, 95% CI 0.60-0.97, n=15,354), alcohol use (OR 0.72, 95% CI 0.56-0.92, n=8,751), physical activity (OR 1.32, 95% CI 1.16-1.50, n=6441, I2 0%) and any antisocial behaviour (OR 0.81, 95% CI 0.66-0.98, n=20,756) and illicit drug use (OR 0.74, 95% CI 0.55-1.00, n=11,058) at up to 12-months. Findings were less certain for illicit drug use (OR 0.74, 95% CI 0.55-1.00, n=11,058) and sexual risk behaviour (OR 0.80, 95% CI 0.60-1.07). Heterogeneity was high for most outcomes (I2 57-77%). There was little evidence of an effect of family interventions and most individual-level interventions. Evidence was rated as moderate or low certainty with very low certainty evidence relating to antisocial behaviour.
Conclusions: Universal school-based interventions that target multiple behaviours may be effective in preventing certain health risk behaviours. These findings may assist with commissioning and policy decisions around public health interventions for young people.
This abstract is based on a pre-peer review version of a Cochrane review. The final version is expected to be published in the Cochrane Database of Systematic Reviews.
Jenny Lloyd
University of Exeter
Effectiveness of the Healthy Lifestyles Programme (HeLP) to prevent obesity in UK primary school children: a cluster randomised controlled trial.
*Lloyd, J1
Senior Research Fellow in Child Health
Creanor S2,, Logan S1, Green C1, Dean S1, Hillsdon M3, Abraham C1,Tomlinson R4, Pearson V5, Taylor RS1, Ryan E6, Price L3, Streeter A2, Wyatt K1
1Institute for Health Research, University of Exeter Medical School
2University Peninsula Schools of Medicine & Dentistry, Medical Statistics Group
3College of Life and Environmental Sciences, University of Exeter
4Royal Devon and Exeter NHS Trust,
5Devon, Devon County Council Commissioning Headquarters
6ISCA Academy
Aim: To determine the effectiveness of the Healthy Lifestyles Programme in preventing obesity in 9-10 year olds.
Background: One third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for this age group.
Methodology: We carried out a cluster RCT, allocating schools (1:1) to either the HeLP intervention or usual school practice. Participants werechildren aged 9-10 years at recruitment and aged 11-12 years at 24 month post baseline follow up. The year-long intervention included four phases: building a receptive environment; a drama-based healthy lifestyles week; 1:1 goal setting and reinforcement activities.The primary outcome measure was BMI SDS at 24 months post baseline measures. Secondary outcomes included waist circumference SDS, % fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometry assessed physical activity and self-reported dietary behaviour at 18 months.
Results: We recruited 32 schools, 14 of which had ≥ 19% pupils eligible for free school meals (the national average for England in 2012) and 1324 children. We had 94% follow up for the primary outcome. The Programme was delivered with high fidelity and engaged children, schools and families across the socioeconomic spectrum. No difference in BMI SDS was found at 24 months (mean difference -0.02 (95% CI: -0.09, 0.05)) or 18 months (mean difference -0.02 (95% CI: -0.08, 0.05)) between children in the intervention and control schools. No difference was found between intervention and control groups in waist circumference SDS, percent body fat SDS or physical activity levels. Significant differences in the type of energy dense snacks and negative food markers were reported, in favour of the intervention.
Conclusions: Despite very high levels of engagement the Healthy Lifestyles Programme is not effective in preventing overweight or obesity in 9-10 year olds suggesting new approaches are needed.
Liam Mahedy
University of Bristol
Liam Mahedy, Senior Research Associate in Epidemiology and Medical Statistics, Population Health Sciences, University of Bristol, UK.
Georgina MacArthur, NIHR Postdoctoral Research Fellow, Population Health Sciences, University of Bristol, UK.
Gemma Hammerton, Senior Research Associate in Epidemiology and Medical Statistics, Population Health Sciences, University of Bristol, UK.
Alexis Edwards, Assistant Professor, Department of Psychiatry and School of Medicine, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Virginia, USA.
Kenneth Kendler, Professor of Psychiatry, Department of Psychiatry and School of Medicine, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Virginia, USA.
John Macleod, Professor in Clinical Epidemiology and Primary Care, Population Health Sciences, University of Bristol, UK.
Matthew Hickman, Professor in Public Health and Epidemiology and Head of Population Health Sciences, University of Bristol, UK.
Simon Moore, Professor, School of Dentistry, College of Biomedical and Life Science, Cardiff University, UK.
Jon Heron, Senior Research Fellow, Population Health Sciences, University of Bristol, UK.
Background/Aim: Evidence demonstrating an association between parental alcohol use and offspring alcohol use from robust prospective studies is lacking. The aim of this study was to examine the influence of parental alcohol use on their children’s alcohol use in young adulthood and assessed the extent that any associations were mediated by parental monitoring, early alcohol initiation, and associating with deviant peers.
Methodology: We used prospective data from a large UK based population cohort (Avon Longitudinal Study of Parents and Children). Data were available on 3,785 adolescents and their parents. Maternal reports of their own and their partner’s alcohol use were collected when their children were 12 years of age. Their children’s self-reported alcohol use was assessed at 18 years of age using the Alcohol Use Disorders Identification Test. Structural equation modelling was used.
Results: There was strong evidence of a total indirect effect from maternal moderate alcohol use to young adult alcohol use via the hypothesised mechanisms (b=.26, 95% CI=.08, .44, p=.001). The majority of this association was explained through earlier alcohol initiation (b=.14, 95% CI=.04, .25, p=.01), and earlier alcohol initiation/associating with deviant peers (b=.06, 95% CI=.02, .10, p<.01). There was strong evidence of a remaining direct effect (b=.81, 95% CI=.39, 1.22, p<.001). A similar pattern of results was evident for partner moderate alcohol use (total indirect effect: b=.46, 95% CI=.28, .64, p<.001). There was also weak evidence of an indirect pathway from partner moderate alcohol use to young adult alcohol use through parental monitoring (b=.06, 95% CI=.01, .10, p=.02), and parental monitoring/peer deviance (b=.11, 95% CI=.01, .06, p=.02). Results for parental high-risk alcohol use were similar to models examining moderate alcohol use.
Conclusions: This prospective study found clear evidence of a potential pathway and prevention target from parental alcohol use and early initiation with alcohol to adverse alcohol use in young adults.
Abstracts for parallel presentation
A1
Zoe Ward
University of Bristol
The cost-effectiveness of interventions to improve case-finding and engagement with Hepatitis C virus treatment for people who inject drugs in the UK
Zoe Ward, Senior Research Associate in Infectious Disease Modelling, University of Bristol
Rosy Reynolds, Senior Research Associate in Medical Statistics, University of Bristol
Graham Harrison, Project Manager for HepCATT, University of Nottingham
William Irving, Professor of Virology, University of Nottingham
Matthew Hickman, Professor of Epidemiology, University of Bristol
Peter Vickerman, Professor of Infectious Disease Modelling, University of Bristol
Background and Aims: People who inject drugs (PWID) are at high risk of Hepatitis C virus (HCV) infection, however approximately 50% are undiagnosed and rates of linkage to care are very low. This study investigated the cost-effectiveness of increasing case finding and engagement with the HCV treatment pathway compared to the status quo in current standard care pathways in drug treatment centres in the United Kingdom.
Methodology: A dynamic HCV transmission and disease progression model of 1000 PWID was parameterised with UK specific data (40% prevalence of chronic HCV) from the Hepatitis C Awareness Through to Treatment (HepCATT) drug treatment centres pilot study. The model estimated the decrease in disease related deaths from 2016 to 2066 if case finding was increased 2.4-fold and engagement onto the HCV treatment pathway was increased 6-fold (data from HepCATT). Costs for the intervention were collected from participating drug treatment centres and HCV treatment delivery costs were updated to reflect direct acting antiviral treatment guidelines. A cost-effectiveness analysis, assuming for HCV treatment with a 50-year time horizon and £20000 per quality adjusted life year (QALY) willingness to pay (WTP) threshold for the incremental cost-effectiveness ratio (ICER) was performed. A cost-effectiveness acceptability curve was calculated from the probabilistic sensitivity analysis.
Results: Increasing case finding and engagement with the HCV treatment pathway averts 69 (95% CI 37-112) deaths over the 50-year time horizon. The mean ICER was £4,193 per QALY, with 100% of the runs cost-effective at the £11,000 per QALY threshold. Univariate analysis showed decreasing HCV treatment drug costs to a quarter of the list price decreased the mean ICER to £1,963 per QALY with 100% of simulations being cost-effective at the £7,000 per QALY threshold.
Conclusions: Increasing case-finding and engagement with HCV treatment in line with recent pilot interventions is cost effective at the £20000 willingness to pay threshold. As the cost of HCV drugs decreases these interventions will become even more cost-effective.
A2
Emma Bird
University of West of England
Psychological predictors of walking and cycling behaviour change: An iConnect study
Bird, EL1, Panter, J2, Baker, G3, Jones, T4, Ogilvie, D5
Senior Lecturer in Public Health, University of the West of England
Senior Research Associate, UKCRC Centre for Diet and Activity Research (CEDAR)
MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine
Chancellor's Fellow, University of Edinburgh
Senior Research Fellow in Sustainable Urban Mobility, Oxford Brookes University
Programme Leader, UKCRC Centre for Diet and Activity Research (CEDAR)
MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine
Aim: This study examined whether an extended version of the Theory of Planned Behaviour (eTPB) predicted change in walking and cycling for transport and recreation using observational cohort survey data collected as part of the wider iConnect study (www.iconnect.ac.uk).
Background: Numerous studies have examined the extent to which the Theory of Planned Behaviour explains and predicts walking and cycling behaviour. However, there has been limited consideration of the psychological factors that predict change in walking and cycling behaviour; factors that may be important in the development of walking and cycling behaviour change interventions.
Methodology: Baseline, 1-year and 2-year follow-up iConnect study data, collected from three UK municipalities (Cardiff, Kenilworth and Southampton), were analysed. Nine psychological constructs from the eTPB as well as weekly time spent (i) walking and (ii) cycling, each (i) for transport and (ii) for recreation, were self-reported at all time points. Multinomial logistic regression was used to examine the associations between baseline eTPB constructs and (i) increases and (ii) decreases in the four behavioural outcomes, adjusted for socio-demographic characteristics.
Results: 1,796 and 1,465 participants provided 1- and 2-year follow-up data, respectively. Time spent walking (minutes per week) increased more than time spent cycling in both samples. All eTPB constructs, with the exception of ‘subjective norms’, were associated with changes in at least one of the four outcomes, but these amounted to relatively few significant associations among the large number tested. In general, eTPB constructs were more often associated with increases than with decreases in time spent walking and cycling.
Conclusions: Findings revealed limited support for the eTPB model as a whole. However, future interventions to promote walking and cycling for transport and recreation through individually delivered approaches might consider fostering the development of positive attitudes, intentions and habits for these behaviours.
A4
Camilla McHugh
University of Exeter
The barriers to and facilitators of healthy lifestyle choices of adolescents transitioning to secondary school.
Anderson L, Lloyd J, Wyatt K
Aim: To explore (i) the barriers and facilitators adolescents cite as influencing their physical activity, food choice and sedentary behaviour at the time of transitioning to secondary school and (ii) their reflections on making behaviour changes to their physical activity and food choices.
Background: In the UK 35% of adolescents (aged 11–15) are overweight and obese. Early adolescence is believed to be a key time to intervene to positively impact obesity related behaviours, and the school provides an ideal setting to delivery interventions; however to date there is little evidence of effectiveness.
Methods: During the autumn term 2016, 53 students aged 11-13 took part in 6 focus groups at 3 secondary schools in Devon, UK. Thematic, framework analysis of the verbatim transcripts was used to analyse the data.
Results: Four key themes emerged: (i) health now and in the future, (ii) the role of others, (iii) provision, temptation and addiction and (iv) boundaries, strategies and support. Transitioning to secondary school was seen as affecting lifestyle choices both positively and negatively. Adolescents demonstrated a good knowledge of what constitutes a healthy lifestyle and its importance for future health, however it was not necessarily a priority at this time in their life. Key people were identified who influenced adolescents. There was also broad agreement on temptations and addictive behaviours leading to unhealthy choices, which were linked to the school and wider environment. The monitoring of choices and behaviours by themselves, parents and schools was also perceived to be important.
Conclusions: There is more that schools could do, at this key developmental stage, to create a healthy school environment and provide support for adolescents to make healthy choices. There is a need to understand the barriers schools face in creating a healthy school ethos and what would enable them to support adolescents to make positive lifestyle choices.
B1
Katharine O’Connor
Plymouth City Council
A comparison between online and paper versions of a risk factor questionnaire used to investigate sporadic cases of food poisoning and foodborne illness: a randomised controlled trial
Katharine O’Connor
Environmental Health Officer, Plymouth City Council
Aim: This randomised controlled trial compared online risk factor questionnaires with postal risk factor questionnaires completed by patients with confirmed foodborne illness. The study was designed to see whether there was a difference in response rate, response time, quality of data and cost of administration between the two groups.
Background: Patients with sporadic cases of foodborne illness are routinely invited to complete a postal investigation questionnaire to help Environmental Health Officers and Health Protection teams identify the likely cause of their infection, and any common exposures that may account for an outbreak of infection. Reductions in resources available to follow up cases and recent large outbreaks of gastro-intestinal infection have highlighted the need for timely and complete information with minimal administrative burden.
This study investigated whether online surveillance may offer a more rapid and efficient way to follow up sporadic cases than the traditional postal method.
Methodology: An online investigation form was created using Qualtrics software. The online form was exported to Word and printed for the postal group. 203 patients with confirmed cases of foodborne illness were randomly assigned to receive either the online form or the postal form. Telephone contact was attempted for all patients to confirm email or postal address details prior to the questionnaires being sent. The Infectious Diseases programme on the Civica APP database recorded the data.
Findings: Response rate and response time was significantly better in the online trial group. There was little difference in completeness and quality of data between the two groups. The online form was more efficient to administer.
Conclusions: Online forms may provide a more rapid and efficient means of data collection for use in sporadic infectious disease follow-up.
B2
Emma Bird – presented by Paul Pilkington
University of West of England
Built and natural environment planning principles for promoting health: An umbrella review
Bird, EL1, Ige2, Pinto, A3,Pilkington, P1
(1) Senior Lecturer in Public Health, University of the West of England
(2) Research Associate in Public Health, University of the West of England
(3) Public Health Manager (Healthy Places), Public Health England
Aim: This umbrella review aimed to assess relationships between the built and natural environment and health, concentrating on five predefined topic areas: neighbourhood design, housing, food environment, natural and sustainable environment, and transport.
Background: The built and natural environment and health are inextricably linked. However, there is considerable debate surrounding the strength and quality of the evidence base underpinning principles of good practice for built and natural environment design in promoting health.
Methodology: A structured search was conducted for quantitative systematic reviews and stakeholder documents published since 2005. Seven databases and the websites of 15 relevant and respected stakeholder organisations known to publish review-level documentation were searched. Searches were limited to English-language publications and duplicate references were removed. Evidence quality and strength was appraised using validated techniques. Findings were used to develop a diagram for each topic area, illustrating relationships between built and natural environment planning principles and health-related outcomes.
Results: A total of 178 systematic reviews and review-level documents were eligible for inclusion. The quality of evidence was mixed, making it difficult to draw clear causal links. Fourteen actionable planning principles associated with positive health-related outcomes were identified across the five topic areas. For example, for the neighbourhood design category, neighbourhoods that enhanced walkability, were complete and compact in design, and those which enhanced connectivity through safe and efficient infrastructure were associated with improvements in health-related outcomes including physical activity, social engagement, mental health, perceptions of crime, and road traffic collisions. Evidence for the effectiveness of planning principles on reducing health inequalities was sparse and inconclusive.
Conclusions: Findings provide an up-to-date overview of relationships between the built and natural environment and health and present logical, evidence-based messages to aid communication between public health and planning professionals.
B3
Kaiseree Dias
University of Bristol
Are diet and physical activity associated with zBMI in 2-4-year olds in North Somerset and Gloucestershire: a cross-sectional study
Er, V Research Associate in Public Health Research, University of Bristol
Dias, K
PhD Student, University of Bristol
Papadaki, A
Senior Lecturer in Nutrition, University of Bristol
White, J
Senior Lecturer in Public Health, University of Cardiff
Metcalfe, C
Professor of Medical Statistics, University of Bristol
Jago, R
Professor of Paediatric Physical Activity and Public Health, University of Bristol
Wells, S
Trial Manager, University of Bristol
Kipping, R
Senior Research Fellow in Epidemiology and Public Health, University of Bristol
Aim: This study examined the associations of diet and physical activity (PA) with body mass index z-score (z-BMI) in pre-school children.
Background: Little is known about the dietary intake and PA of pre-schoolers in childcare settings and their association with body weight.
Methodology: Cross-sectional study of 150 pre-school children aged 2-4-years who participated in the NAP SACC UK feasibility trial. Diet quality was assessed according to children’s adherence to the Children’s Food Trust guidelines through observation in nurseries. PA was measured using accelerometers. We derived age- and sex-adjusted BMI using the UK1990 and IOTF growth reference charts. Multilevel linear and logistic regression models were used to adjust for age, gender, ethnicity, parental education level and clustering.
Results: Pre-schoolers’ diet quality was not associated with zBMI or weight status. The proportion of children meeting the dietary standards was <70% for fruits and vegetables and <75% for high sugar or fat snacks. Of the 114 children with PA data, 11.4% met the daily PA guidelines of 180 minutes. Minutes spent in light PA (β = 0.08, 95% CI = 0.01, 0.15) and active time (β = 0.07, 95% CI = 0.01, 0.12) were positively associated with zBMI based on the UK1990 growth reference chart. Similar associations were observed for IOTF-derived zBMI. The odds of being overweight/obese using the UK1990 thresholds was higher in more active children (OR = 1.13, 95% CI = 1.02, 1.25) and lower in children who spent a higher proportion of time sedentary (OR = 0.89, 95% CI = 0.80, 0.98).
Conclusions: The study showed evidence that time spent in light PA and active time was positively associated with higher zBMI. While the diet quality consumed in nurseries was good, the low proportion of children meeting recommended PA guidelines highlights that more work is needed to increase pre-schoolers’ PA.
B4
Caroline Wright
University of Bristol
Are psychosocial factors in late childhood and mid-adolescence associated with multiple risk behaviours at age 16: analysis using the ALSPAC birth cohort
Dr Caroline Wright[1], Dr Ruth Kipping[2], Professor Matthew Hickman[3], Professor Rona Campbell[4], Dr Jon Heron[5]
[1]Research Associate, Bristol Medical School, University of Bristol, UK.
2Senior Research Fellow in Epidemiology and Public Health, Bristol Medical School, University of Bristol, UK.
3Professor in Public Health and Epidemiology, Bristol Medical School, University of Bristol, UK.
4Professor of Public Health Research, Bristol Medical School, University of Bristol, UK.
5Senior Research Fellow, Bristol Medical School, University of Bristol, UK.
Key words: Multiple risk behaviours, adolescence, psychosocial factors, mediation analysis, structural equation modelling, ALSPAC, UK birth cohort study
Aims: To explore the potential mediating pathways between psychosocial factors in late childhood and mid-adolescence and multiple risk behaviours (MRB) at age 16 years.
Background:Engagement in MRB is associated with adverse health outcomes in later life, including chronic health conditions, morbidity and premature mortality. It is therefore important to understand the antecedents of MRB.
Methodology: Data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a birth cohort of children born in England between 1991-3 were used to explore pathways from late
childhood through to adolescence. Using structural equation models, we explored the associations
between depressive symptoms and antisocial behaviour at age 10 and sensation seeking at age 11; and MRB at age 16 years. We also explored potential mediating pathways through: self-image, social relations at school, perception of teachers and perception of school at age 14 years and experimentation with tobacco, alcohol or cannabis, before age 13 years.
Results: There are strong associations between depressive symptoms (0.22, 95%CI=[0.12,0.31], p<0.001), antisocial behaviour (0.44, 95%CI=[0.32,0.56], p<0.001) and sensation seeking (0.58, 95%CI=[0.49,0.66] p<0.001) in late childhood and higher MRB at age 16 years. We also found strong evidence of mediating pathways through depressive symptoms and negative perception of school (0.04, 95%CI=[0.02,0.06], p<0.001) and negative perception of teachers (0.06, 95%CI=[0.03,0.08], p<0.001); from sensation seeking through negative perception of teachers (0.05, 95%CI=[0.03,0.08], p<0.001) and early experimentation with tobacco, alcohol or cannabis (0.09, 95%CI=[0.08,0.11], p<0.001); and from antisocial behaviour through negative perception of school (0.04, 95%CI=[0.02,0.07], p=0.001) and higher MRB at age 16 years.
Conclusions: There were strong associations between psychosocial factors in late childhood and higher MRB at age 16 years. Whilst these three psychosocial factors were related, there were distinct mediating pathways through factors in mid-adolescence. These results provide evidence of important targets for interventions aimed at reducing adolescent MRB.
C1
Louisa Forbes
Royal Cornwall Hospital Trust
Improving the management of UTI in nursing Homes: An antibiotic stewardship intervention
Louisa Forbes
Lead Nurse Educator, Bug and Drug project, Royal Cornwall Hospital trust (RCHT).
Neil Powell,
Consultant Antimicrobial Pharmacist, RCHT.
Louise Silver,
Lead Nurse Educator RCHT.
Aim and Background: The Chief Medical Officer reports there to be fewer public health issues of greater importance than that of Antimicrobial Resistance (AMR) (1). Antibiotic use is the single biggest driver for AMR and as such reducing unnecessary antibiotic use is key to slowing the evolution of AMR. A Nurse Led Project began in 2016 to raise awareness of AMR and promote antibiotic stewardship across Cornwall with a focus on appropriate UTI management. We set out to implement the SIGN 88 UTI guidance (2) with the following objectives;
•Decrease inappropriate antibiotic prescribing for UTI’s
•Decrease inappropriate use of urinary dipsticks in residents >65yrs
•Review use of antibiotic prophylaxis for UTI’s
•Estimate the health-economic impact of this intervention
Methodology: A tool for diagnosing and managing urinary tract infections was developed and introduced to four nursing homes, with a total of 157 beds, in West Cornwall. The tool was ratified with relevant organisations and specialists. We then facilitated focus groups with the nursing home managers to ensure engagement and adoption of the UTI tool. The tool was implemented over a 3 months period and included an education package to support care staff. The following were measured pre and post intervention; number of UTI diagnoses, number of urine dips performed, number of antibiotic treatment courses, number of antibiotic prophylaxis courses. Staff time to diagnose and manage UTI was estimated and coupled with any reductions in UTI diagnoses used to develop a model to estimate potential health-care cost savings.
Results: The key findings showed a 66% reduction in UTI diagnosis, 86% reduction in urine dipstick use and 92% reduction in use of UTI prophylaxis.
This data was transferred into a cost saving model which estimated this pilot would have saved £3,700 annually at the four care homes in reduced human resource expenses (e.g. GP and carer time) and consumables (e.g. medications and urine dips).
For the 235 care homes in Cornwall, 5349 beds, we estimate £500,000 saving over 12 months
Conclusions: The implementation of the UTI tool in combination with education on UTI management reduced antibiotic use with large potential savings across the health-care system.
C2
Suzanne Aubrey presented by Harriet Batista Ferrer
University of Bristol
Mode of travel to work: Contribution to objectively measured physical activity, and associations with individual, interpersonal, organisational, and environmental characteristics
Audrey S
Senior Research Fellow in Public Health
Aim: To examine, and compare by travel mode, the objectively measured physical activity of a working adult population, and identify associations between mode of travel to work and individual, interpersonal, organisational and environmental characteristics.
Background: Encouraging walking during the daily commute is a potential strategy for increasing physical activity levels. Understanding factors that facilitate walking can help guide the development of effective interventions.
Methods: Employees (n=654) recruited from 87 workplaces in south-west England and South Wales provided data about their commute through wearing accelerometers and Global Positioning System receivers, and completing travel diaries and questionnaires. Separate multivariable logistic regression models were developed to examine factors associated with mode of travel to work and levels of physical activity during the commute.
Results: In comparison to car users, walkers and public transport users accrued substantially higher levels of daily Moderate to Vigorous Physical Activity (MVPA) during the commute (34.3±18.6 vs. 7.4±7.6 minutes, p<0.001) and throughout the day (71.4±21.3 vs. 45.7±20.9 minutes, p<0.001). Participants in non-sedentary occupations were less physically active during their commute (p<0.05). Factors associated with walking to work included a commute distance of less than two kilometres (p<0.001) and absence of free work car parking (p<0.01). Compared to car users, walkers had more favourable perceptions of the suitability and maintenance of pavements (p<0.01), traffic safety (p=0.02), lighting (p=0.02), and the environment (p=0.02) along their commute.
Conclusions: Walking during the commute to work (the whole route or combined with public transport) is an important contributor to objectively measured physical activity levels. Interventions should take into account both individual and wider determinants of commuting behaviour. These include commuting distances, availability of car parking, perceptions of commuting routes and alternative modes of transport. Encouraging and supporting walking during the daily commute should be a priority for transport, urban planning and public health disciplines.
C3
Laura Tinner
University of Bristol
Are quality of life and family expenditure on physical activity associated with physical activity in 2-4-year-olds in North Somerset and Gloucestershire?
Laura Tinner1, Ruth Kipping2, James White3, RussellJago4, Chris Metcalfe5, William Hollingworth6
1PhD Student, Population Health Sciences, University of Bristol, UK
2 Senior Research Fellow, Population Health Sciences, University of Bristol, UK
3Senior Lecturerin Public Health, Centre for Trials Research, University ofCardiff, UK
4Professor of Paediatric Physical Activity and Public Health, School for Policy Studies, University of Bristol, UK
5Reader in Medical Statistics, Population Health Sciences, University of Bristol, UK
6Professor of Health Economics, Population Health Sciences, University of Bristol, UK
Aim: To examine association between pre-school children’s quality of life and family expenditure on physical activity with children’s physical activity.
Background: Despite the well-described health benefits associated with physical activity many children do not engage in the recommended level of physical activity. To inform public health interventions, there is a need to determine factors associated with physical activity in children.
Methods: Cross-sectional study with 81 UK preschool children in North Somerset and Gloucestershire from the NAPSACC UK feasibility RCT. Descriptive statistics with results from student t-tests to determine differences by gender, age and parental education and compare physical activity on nursery and non-nursery days. The associations between physical activity, quality of life (PedsQL) and family expenditure on physical activity were assessed using mixed effects linear regression models.
Findings: 88.89% of children did not meet UK guidelines of 180 minutes of physical activity per day. Children spent a mean (SD) of 141.90 (33.10) minutes per day being physically active and 22.21 (9.87) in moderate vigorous physical activity (MVPA). Children spent more minutes per day being physically active on nursery than non-nursery days (146.89 vs. 137.22, p= 0.05). There was no association between parental expenditure on physical activity with minutes active or minutes in MVPA. There was weak evidence of an association between Tertile 3 PedsQL physical functioning (scores 93.76-100) and higher levels of MVPA (4.06 95% CI: -0.41–8.54, p-value 0.07).
Conclusions: Initiatives are needed to help nursery-age children meet UK physical activity guidelines. Children were more active on nursery days. Higher expenditure by parents on physical activity was not associated with higher activity levels amongst children. There was weak evidence of an association between better PedsQL physical scores and increased levels of MVPA. Further examination of these associations in larger datasets will help to inform design of public health interventions.
Poster presentations – sessions D1-D4 – please see poster list
E1
Rachael Biggart
University Hospitals Bristol NHS Trust
No impact of rotavirus vaccination on childhood seizure hospitalizations in England
Biggart R1, Finn A2, Marlow R3
1 Academic Foundation Year 2 Trainee, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
2 Professor of Paediatrics, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
3 Clinical Lecturer in Paediatric Emergency Medicine, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
Aim: This study investigated whether a potential protective association exists between rotavirus vaccination (RV) and admissions with childhood seizures (CS) in England 2007-2017.
Background: Studies have identified rotavirus infection as an under-recognised cause of childhood seizures. In the US a large retrospective cohort study found in the year following RV a 20% reduction in the risk of seizures requiring emergency department (ED) attendance or hospital admission. With similar findings from Australia and Northwest Spain, England is opportunely placed to explore unintended benefits of RV, given its well-defined introduction into our immunisation schedule in July 2013 and high uptake (>95%).
Methodology: Hospital Episodes Statistics (HES) are centralised records of all NHS hospital admissions in England. Within this dataset, we identified admissions with febrile and afebrile seizures in children less than 16 years old (ICD-10 codes; G40*, G41*, R56.0*) between April 2007 and March 2017, fitting separate regression models for this count data, offset for English population changes with vaccine use as a covariate.
Results: Our 10-year time series analysis found no change in admission patterns for afebrile seizures and predating RV rollout a decreasing trend in admissions with febrile convulsions. The negative binomial distribution provided the best fit to the data, however our model did not detect a statistically significant association between RV and admission with febrile (p=0.84), afebrile (p=0.83) or all (p=0.93) seizures.
Conclusions: Despite not finding a protective association, it remains important for us to document changing baseline seizure admission rates, given their significant healthcare resource use. The strength of this ecological study is its robust size, comparing ten year trends across the whole of England. A limitation is its selection in solely examining hospital admissions. Building on this piece of work we are going to conduct a similar time series analysis on presentations to ED with childhood seizures.
E2
Abigail Russell
University of Exeter
What is the current provision and future need for student self-harm prevention and intervention in secondary schools? A survey and qualitative consultation
Abigail Russell1, Astrid Janssens2, Rhiannon Evans3, and
The Self-harm and Suicide in Schools GW4 Research Collaboration4
1 Postdoctoral Research Fellow, University of Exeter Medical School
2 Senior Research Fellow, University of Exeter Medical School
3 Senior Lecturer, DECIPHer, School of Social Sciences, Cardiff University
4 Academics from the Universities of Exeter, Bath, Cardiff and Bristol
Background: Self-harm prevalence in UK adolescents is estimated at 6.9% to 18.8%. It is a growing concern: hospital admissions for self-harm in under-25’s increased 68% between 2001 and 2011. Research and policy has called for extensive investment in innovative school-based prevention of self-harm. To date there is no evidence-based approach for the assessment and treatment of self-harm without suicidal intent in educational settings. This study therefore aimed to assess current provision for prevention and intervention in self-harm, and explore barriers and facilitators to implementing strategies to address self-harm in schools.
Methods: A cross-sectional survey was conducted with secondary schools in Wales and South-West England in 2016, with an embedded qualitative consultation. Secondary schools in Wales were recruited via the existing School Health Research Network and all eligible secondary schools in the local authority areas of Devon, Plymouth, Torbay and Somerset were approached: 153 schools took part in the survey phase. Eight focus groups were conducted for the qualitative consultation that further explored the survey findings.
Results: Those most involved with responding to self-harm were pastoral care teams (97%); school counsellors; school nurses; and CAMHS (each 92%). Teaching staff were involved in 74% of schools. Students were least frequently involved (45%). Qualitative analysis found that schools are in need of a better knowledge of self-harm as well as a need to be equipped with strategies that they can use to address this.
Discussion: Schools take a reactive approach to self-harm, dealing with instances once they occur: attributed to fear of “contagion” of self-harm. Future interventions must consider communication between home and school; appropriate training in strategies to prevent and address self-harm; time and resources to implement training; addressing concerns about legal implications and responsibility, and removing stigma around self-harm whilst promoting effective alternate coping strategies.
E3
Katie Currie
Bristol City Council
Title:A grounded theory analysis of the experiences of dementia of people from three BME communities: balancing the need for support against fears of being diminished.
Authors: Professor Richard Cheston (UWE), Subitha Baghirathan (UWE), Rosa Hui (Bristol & Avon Chinese Women's Group), Anderloris Chacon (Bristol Back Carers), Paula Shears (Formerly Alzheimer’s Society) and Katie Currie (Bristol City Council)
Aim: To understand the experience of dementia of people from three BME communities in Bristol in order to inform practice.
Background: An estimated 25,000 people of Black, Asian and other Minority Ethnic (BME) origins live with dementia in UK - a number which is expected to increase seven-fold by 2051. Many people from BME communities experience dementia in a markedly different way to their white British counterparts. For instance diagnosis is more likely to occur at an advanced stage of the illness while there is a lower take-up of mainstream dementia services. Bristol has a culturally diverse and ageing population. This has important implications for local dementia care.
Methodology: This research study focused on people of Caribbean, South Asian and Chinese origins who had experience of dementia and were living in Bristol. Central to the research were collaborative partnerships developed between researchers and Voluntary and Community Sector Organisations (VCSOs) led by older people of BME origins. Through these partnerships, 48 participants were recruited for one-to-one interviews and 8 Focus Groups were carried out.
Findings: Knowledge of dementia varied across these three BME communities. Participants’ experiences of inequalities affected their perceptions of the symptoms of dementia and their take-up of mainstream services. BME-led VCSOs played a vital role in providing care including educating their members about dementia, providing ongoing support and advocating on behalf of people with dementia and their families.
Conclusions: More sustainable and equitable resourcing of BME-led VCSOs would better equip local dementia care to meet the increasing future needs of people of BME origins with dementia. New approaches to sharing information about dementia risk factors and ‘living well with dementia’ with BME communities are necessary. Given the increasing importance of cultural diversity within dementia care, this study has important implications for communities across the UK and elsewhere.
E4
Zoe Ward – presented by Rosy Reynolds
University of Bristol
Evaluation of an intervention designed to increase diagnosis and treatment of patients with hepatitis-C virus infection in drug treatment settings
Graham Harrison, Project Manager for HepCATT, University of Nottingham
Matthew Hickman, Professor of Epidemiology, University of Bristol
Zoe Ward, Senior Research Associate in Infectious Disease Modelling, University of Bristol
Rosy Reynolds, Senior Research Associate in Medical Statistics, University of Bristol
William Irving, Professor of Virology, University of Nottingham
Background: The advent of directly acting antiviral therapy for chronic hepatitis C virus (HCV) infection increases the rationale for identification and treatment of infected individuals. This is not straightforward in the high-risk group of people who inject drugs (PWID) attending Specialist Community Drug Services (SCDS). The HepCATT study aimed to explore the effectiveness and cost effectiveness of a complex intervention in SCDS in increasing HCV diagnosis, referral, assessment, engagement and treatment of PWID via routine clinical pathways.
Methods: We piloted a 12-month intervention at 3 SCDS in the UK. This included appointment of a facilitator to coordinate a range of activities aimed at increasing diagnosis and enhancing patient referral including staff and patient educational initiatives, enhancement of peer support teams, introduction of dried blood spot testing, and integration of HCV assessment and treatment where possible with opiate substitution therapy. Five sites not chosen as intervention sites acted as controls. The primary endpoint was clinical engagement with therapy, defined as patient had completed 1) investigations including viral load and genotype 2) assessment of liver disease stage by fibroscan, serum fibrosis markers or biopsy and 3) a consultation regarding their treatment options.
Results: Data showed between ~3 & 10-fold increases in the odds of referral, and between ~3 & 18-fold increases in the odds of attendance and levels of treatment engagement at all sites. Control sites changed little from baseline levels. The effective components of the facilitator-mediated intervention and reasons for patient drop-out at all points along the care pathway will be presented.
Conclusion: The introduction of nurse facilitators within drug treatment settings increases testing and patient referrals and can lead to significant increases in engagement and treatment of PWID within routine clinical care pathways.
F1
Filiz Altinoluk-Davis
NHS England/Public Health England
Measuring the effectiveness of catch-up MMR delivered by school nurses compared to signposting to general practice on improving MMR coverage: a retrospective cohort study.
Filiz Altinoluk-Davis
University of the West of England – MSc Public Health dissertation
Supervisory team: Prof. Selena Gray; Dr. Issy Bray; Prof. Jane Powell
Aim: This study aims to determine the extent to which increased coverage of at least one dose and two doses of MMR differs between areas in which school nurses deliver catch-up MMR doses to adolescents in school settings, compared to signposting to general practice.
Background: In 2016 the number of cases reported in England had risen more than five times to 531 compared to 92 cases in 2015.1 Analysis suggests the burden of disease has shifted to older teenagers and young adults; the majority of whom are unimmunised.2,3
Methodology: A retrospective cohort study was conducted using secondary data from Child Health Information Services within the NHS England South (South Central) commissioning boundary. The sample population includes children born 1 September 2000–31 August 2001 who were in school year 9 during the 2014/15 academic year. Children attending schools in Berkshire, Buckinghamshire, Oxfordshire and Swindon were grouped together as Cohort 1 (school nurse delivery); and students from Bath & North East Somerset and Gloucestershire were grouped in to Cohort 2 (general practice delivery).
Results: The analysis included 27,527 records, and was completed using the chi-squared comparison of proportions test. The results show an increase in coverage of at least one dose of MMR by 1.60% between baseline (01/09/2014) and the end of the follow-up period (31/08/2016). Similarly, there is an increase of 1.45% in coverage of two doses of MMR. The findings also suggest that school nurse delivery of catch-up MMR may benefit children of BAME ethnicity and those from more deprived backgrounds, as coverage increased by 1.72% and 2.84%, respectively, in these groups.
Conclusions: The findings suggest school-based delivery of catch-up MMR improves coverage. Based on these findings it is recommended that commissioners of school-aged immunisation services incorporate the delivery of catch-up MMR doses within their contracts with school nurses.
References
1 PHE (2017a) Laboratory confirmed cases of measles, mumps and rubella, England: October to December 2016. Health Protection Report 11 (8).
2 PHE (2016a) Laboratory confirmed cases of measles, mumps and rubella, England: April to June 2016. Health Protection Report 10 (25).
3 PHE (2016b) Laboratory confirmed cases of measles, mumps and rubella, England: July to September 2016. Health Protection Report 10 (41).
F2
Sarah Harding
University of Bristol
Is teachers’ mental health associated with their students’ mental health and wellbeing? A cross sectional study”.
Authors
Sarah Harding, Dr., Research Associate in Public Health, University of Bristol,
Richard Morris, Prof., Professor in Medical Statistics, University of Bristol,
David Gunnell, Prof., Professor of Epidemiology, University of Bristol
Tamsin Ford, Prof., Professor of Child and Adolescent Psychiatry, University of Exeter
William Hollingworth, Prof., Professor of Health Economics, University of Bristol
Kate Tilling, Prof., Professor of Medical Statistics, University of Bristol
Rhiannon Evans, Dr., Senior Lecturer, Cardiff University,
Sarah Bell, Dr., Senior Research Associate in Public Health, University of Bristol,
Jillian Grey, Dr., Research Assistant, Cardiff University,
Rowan Brockman, Dr., Senior Research Associate in Public Health, University of Bristol,
Rona Campbell, Prof., Professor of Public Health Research, University of Bristol,
Ricardo Araya, Prof., Clinical Professor in Global Mental Health, King’s College London,
Judi Kidger, Dr., Senior Research Fellow in Public Health, University of Bristol,
Aim: To understand whether teachers’ wellbeing and depression is associated with the mental health and wellbeing of their students’.
Background: Despite the likelihood that teacher and student wellbeing and poor mental health is linked, evidence for this is currently lacking in the literature.
Methodology: Cross-sectional data were collected from 3217 Year8 (aged 12-13 years) students and from 1167 teachers in 25 secondary schools in England and Wales. The association between teacher wellbeing (Warwick Edinburgh Mental Wellbeing Scale mean) with i) student wellbeing (Warwick and Edinburgh Mental Wellbeing Scale) ii) student psychological distress (Total Difficulties Score (TDS) on the Strengths and Difficulties Questionnaire (SDQ)) were assessed using random effects mixed models. Analyses were repeated using teacher depression (Patient Health Questionnaire) as the explanatory variable.
Results: Better teacher wellbeing was associated with i) better student wellbeing (standardised effect =0.07, 95% CI = 0.02 to 0.12) and ii) lower student psychological distress (standardised effect =-0.12, 95% CI = -0.17 to -0.06). These associations were attenuated by up to two thirds when the quality of the teacher-student relationship and teacher presenteeism (under-performing at work due to health problems) were included in the models. Higher levels of teacher depressive symptoms were associated with poorer student wellbeing (standardised effect = -0.06, 95% CI = -0.11 to -0.01). This effect was lost when teacher presenteeism was included in the model.
Conclusions: Cross-sectional associations were found between teacher wellbeing and i) student wellbeing and ii) and between student psychological distress, and between teacher depression and student wellbeing. These may be at least partially explained by teacher presenteeism and positive teacher-student relationships.
F3
Nasrul Ismail
University of West of England
What are the barriers faced by prison governors and staff in implementing the Healthy Prisons Agenda in England?
Nasrul Ismail, ESRC PhD Researcher in Public Health, Bristol Centre for Public Health and Wellbeing, University of the West of England (UWE) Bristol, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY.
Nick de Viggiani, Senior Lecturer, Bristol Centre for Public Health and Wellbeing, UWE Bristol, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY.
Aim: This research investigated the barriers faced by prison governors and staff in implementing the Healthy Prisons Agenda in England. It focused on prisons as a workplace, since prison governors and staff spend more time in prisons than the prisoners themselves.
Background: Existing studies highlight the conventional reasons for why prison rehabilitation is not appreciated: a prevailing focus on security and scepticism regarding the health agenda.
Methodology: We conducted semi-structured interviews (average 37 minutes) with 30 key prison decision-makers in England. Grounded Theory was used to construct “barriers” to realising the Healthy Prisons Agenda. Participants were recruited using purposive, theoretical, and snowball methods. Data analysis was conducted using NVivo 11 and completed in an iterative cycle, using open, focused and axial coding. Transcripts were analysed until data saturation was achieved.
Findings: At the macro level, decreased resources, gaps in workforce planning and unfavourable employment terms have reduced prison staffing levels by 30%. This reduction, along with prison instability, has forced prison staff to prioritise reactive tasks over the Healthy Prisons Agenda.
At the meso level, the prevailing focus on security and a lack of strategic guidance on how to implement the Agenda are evident. At the micro level, prison officers’ scepticism towards the Agenda, particularly regarding its utility for themselves and prisoners, remains widespread. Equally, it is not entirely pragmatic to fully embrace the Agenda, due to the consequences of the reduction in resources at the macro-level.
Conclusions: This is the first interdisciplinary qualitative study to explore how health policy and politics and organisational behaviour profoundly affect the delivery of the Healthy Prisons Agenda in English prisons. The allocation of additional resources and a paradigm shift by prison governors and staff in appreciating prison rehabilitation may promote the longevity of the Healthy Prisons Agenda in England.
F4
Simon Packer
Public Health England
MRSA in people who inject drugs: prevalence, risk factors and molecular epidemiology
Keywords: Methicillin-Resistant Staphylococcus aureus; Drug Users; Substance Abuse, Intravenous; Sequence Analysis, DNA;
Authors: Simon Packer, Field Epidemiology Training programme fellow, Field Epidemiology Service, Public Health England, Bristol.
S. Thompson Senior Biomedical Scientist, Public health laboratory Bristol, Public Health England, Bristol.
B. Pichon, Bioinformatician, Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, London.
J. Neale, Team lead, Bristol Drugs Project, Bristol.
J. Njoroge, Scientist, Unlinked Anonymous Monitoring survey of people who inject drugs, Public Health England, London
R. Kwiatkowska, Specialty Registrar Public Health, Field Epidemiology Service, Public Health England, Bristol.
I. Oliver, Regional Director, Field Epidemiology Service, Public Health England, Bristol.
M. Telfer, CEO, Bristol Drugs Project, Bristol.
C. Buunaaisie, Masters in Public Health student, University of West England, Bristol.
E. Heinsbroek, Principle Scientist, Unlinked Anonymous Monitoring survey of people who inject drugs, Public Health England, London
N. Hopewell-Kelly, Research fellow (Patient and Public Involvement lead, UWE/Health Protection Research Unit evaluation of interventions.
M. Desai, Consultant epidemiologist, Unlinked Anonymous Monitoring survey of people who inject drugs, Public Health England, London
V. Hope, Professor of Public Health, Public Health Institute, Liverpool John Moores University, Liverpool and Unlinked Anonymous Monitoring survey of people who inject drugs, Public Health England, London and Public Health Institute
M. Williams, Consultant microbiologist, Public health laboratory Bristol, Public Health England, Bristol.
A. Kearns, Head of Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, London.
M. Hickman, Professor of Public Health and Epidemiology, School of Social and Community Medicine, University of Bristol, Bristol and NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol.
M. Gobin, Consultant epidemiologist, Field Epidemiology Service, Public Health England, Bristol.
Aim: We aimed to conduct a base line study to characterise and estimate the prevalence of MRSA colonisation in PWID and use whole genome sequencing (WGS) to test evidence of a clonal outbreak of MRSA in PWID.
Background: In 2015 Bristol in the South West of England experienced a substantial increase in the number of community acquired cases of methicillin resistant Staphylococcus aureus (MRSA) infection in people who inject drugs (PWID).
Methods: In late 2016, 153 PWID in the City of Bristol were recruited through a community survey. Participants completed a behavioural questionnaire and were swabbed for MRSA. Univariate logistic regression was used to identify factors associated with MRSA colonisation. Phylogenetic analysis was performed on lineage-matched MRSA from: Bristol PWID (screening samples and retrospective bacteraemia) and non-PWID (screening) and reference lab database isolates.
Results: The MRSA colonisation prevalence was 9%. Colonisation was associated with frequently injecting outside (OR:5.5, 95% CI:1.34-22.7), hospital contact in past month (4.3, 95% CI:1.34-13.80) and injecting in groups of three or more (15.8, 95% CI:2.51-99.28). Persons reporting one of: injecting outside, injection site skin and soft tissue infection or hospital contact accounted for 12/13 MRSA positive cases (sensitivity 92.3%; specificity 51.5%). The majority of carriage isolates belonged to a single lineage (CC5). Phylogenetic analysis identified three distinct genetic clusters with evidence of a dominant clade associated with infection and colonisation among PWID, and two more genetically distant clades.
Conclusions: MRSA colonisation in PWID in Bristol is substantially elevated compared to population estimates (<0.1%-1.5%). The data provides evidence of community-based transmission and increased infection risk depending on colonising strain and injecting practice. Targeted interventions, such as community screening, enhanced wound care and suppression therapy, are needed to reduce MRSA infections in PWID. Further development work, novel ideas and evaluation of methods are required.