Scientific Conference Plenary and Parallel Session Abstracts 2017

Abstracts for presentation

PLENARY

Caroline Wright

University of Bristol

The effect of multiple risk behaviours in adolescence on educational attainment at age 16 years: a UK birth cohort study

Dr Caroline Wright , Dr Ruth Kipping , Professor Matthew Hickman , Professor Rona Campbell , Dr Jon Heron 

 

^[1]Research Associate, School of Social and Community Medicine, University of Bristol, UK.

^[1]Senior Research Fellow in Epidemiology and Public Health, School of Social and Community Medicine, University of Bristol, UK.

^[1]Professor in Public Health and Epidemiology School of Social and Community Medicine, University of Bristol, UK.

^[1]Professor of Public Health Research, School of Social and Community Medicine, University of Bristol, UK.

^[1]Senior Research Fellow, School of Social and Community Medicine, University of Bristol, UK.

 

Aim: To estimate the association between engagement in multiple risk behaviours (MRB) during adolescence and educational attainment at age 16 years.

Background: Single health risk behaviours are negatively associated with educational outcomes, but any relationship between MRB and educational attainment has not been explored. We assessed the extent to which simultaneous engagement in MRB during adolescence is associated with examination performance at age 16 years.

Methodology: Data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a population based birth cohort study of children born in England between 1991 and 1992 were used in linear and logistic regression analyses. We estimated the association between the total number of a wide range of health risk behaviours (including tobacco smoking, hazardous alcohol use and TV viewing) ranging from 0 to 13 behaviours, and educational attainment. The outcomes were: capped General Certificate of Secondary Education (GCSE) score and odds of attaining five or more GCSEs at grades A*-C. Multiple imputation was used to account for missing data.

Results: We found that engagement in MRB was strongly associated with poorer educational attainment and each additional risk equated to a one grade reduction in capped GCSE score or reduced odds of attaining five or more A*-C grades of 23%. The average cohort member engaged in 3 MRBs and would therefore have an associated reduction in their GCSE examinations equivalent to three grades in one examination, or reduced odds of attaining five or more A*-C grades of 69%.

Conclusions: Engagement in MRB during adolescence is strongly associated with poorer educational attainment at age 16 years. Preventing MRB could improve educational attainment and thereby directly and indirectly improve longer term health outcomes. 

PLENARY

Ruth Kipping

University of Bristol

Feasibility cluster randomised controlled trial and process evaluation of an environmental intervention in nurseries and a web-based home intervention to increase physical activity, oral health and healthy eating in children aged 2–4 years: NAP SACC UK

Dr Ruth Kipping¹, Dr Beki Langford², Dr James White³, Dr Chris Metcalfe⁴, Dr Angeliki Papadaki⁵, Professor William Hollingworth⁶,Professor Laurence Moore⁷, Professor Rona Campbell⁸,Professor Dianne Ward⁹, Dr Rowan Brockman¹⁰, Ms Sian Wells¹¹, Dr Alex Nicholson¹², Mrs Jane Collingwood¹², Professor Russell Jago¹³

 

¹Senior Research Fellow, School of Social and Community Medicine, University of Bristol, UK

² Senior Research Associate, School of Social and Community Medicine, University of Bristol, UK

³Senior Lecturerin Public Health, School of Medicine, University of Cardiff

⁴Reader in Medical Statistics, School of Social and Community Medicine, University of Bristol, UK

⁵Senior Lecturer in Nutrition, School for Policy Studies, University of Bristol, UK

⁶Professor of Health Economics, School of Social and Community Medicine, University of Bristol, UK

⁷Director, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK

⁸Professor of Public Health Research, School of Social and Community Medicine, University of Bristol, UK

⁹Professor of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA

¹⁰ Research Associate, School of Social and Community Medicine, University of Bristol, UK

¹¹Trial Manager, School of Social and Community Medicine, University of Bristol, UK

¹²Trial Coordinator, School of Social and Community Medicine, University of Bristol, UK

¹³Professor of Paediatric Public Health, School for Policy Studies, University of Bristol, UK

 

Aim: To examine the feasibility and acceptability of adapting the NAP SACC (Nutrition and Physical Activity Self Assessment for Child Care) intervention from the US to the UK.

Background: Systematic reviews have identified the lack of intervention studies to prevent obesity in young children. Most 3 year old children in the UK attend formal childcare and these settings present an opportunity to improve health.

Methodology: A feasibility cluster randomised controlled trial in 12 nurseries with 2-4 year olds in North Somerset and Gloucestershire. The intervention comprised: two staff workshops on physical activity and nutrition; health visitor support to review nursery practices and make changes; and a digital media-based home component. Measures were assessed at baseline and post-intervention: zBMI, accelerometer-measured physical activity and sedentary time, diet, child quality of life, health care usage, parental and nursery staff mediators and nursery environment quality. Fidelity and acceptability were assessed through observation and interviews.

Results: 168 children (37% of eligible children) were recruited from 12 nurseries. Interviews were completed with four health visitors, 17 nursery staff and 20 parents. The intervention was implemented with high fidelity except: one nursery did not implement the intervention due to staff workload; and the digital home component was used by 12 (14%) parents. Intervention acceptability was high. The mean number of staff per nursery attending workshops was seven. The workshops and health visitor contact were highly valued. The mean number of goals set was eight. Changes made included: menu modifications, reducing portion sizes and sugary snacks, role modelling physical activity and eating, and active story telling. The trial design and methods were highly acceptable.  Descriptive analysis of the outcomes will be available by February 2017.

Conclusions: NAP SACC UK is feasible and acceptable with the exception of the home component; effectiveness should be tested through a full-scale RCT.

 

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Abstracts for parallel presentation

 

A1

Kyla Thomas

University of Bristol

The Effects of Varenicline on Adverse Outcomes: an Observational Cohort Study Using Electronic Medical Records

 

Davies NM, Taylor GM, Taylor AE, Jones T, Martin RM, Munafo MR, Windmeijer F, Thomas KH.

Consultant and Clinical Lecturer in Public Health

Aim: To investigate the effects of prescribing varenicline or nicotine replacement therapies on adverse outcomes up to four years after treatment.

Background: Concerns have been raised about the cardiovascular safety of varenicline and there is limited evidence on the long-term health outcomes of patients prescribed smoking cessation therapies.

Methodology: We conducted a retrospective observational cohort study of patients prescribed smoking cessation prescriptions (varenicline versus nicotine replacement therapy (NRT)) using validated data from the Clinical Practice Research Datalink (CPRD). We sampled 126,718 patients from across the UK who were issued prescriptions between 1st of September 2006 and the 31st of March 2014. We used three approaches to overcome potential residual confounding: multivariable adjusted, propensity score matched and instrumental variable regression. Our primary outcome was all-cause mortality two years after the first prescription. Our secondary outcomes were cardiovascular and respiratory disease mortality, all-cause, cardiovascular, and respiratory disease-related hospitalization, incident primary care diagnosis of myocardial infarction or chronic obstructive pulmonary disease, and frequency of primary care attendance.

Results: In a multivariable-adjusted analysis, mortality was lower amongst patients prescribed varenicline (odds-ratio=0·78 95% confidence interval (95%CI):0·69 to 0·87), as was hospitalization (odds-ratio=0·85, 95%CI: 0·83 to 0·88), but there were similar rates of incident myocardial infarction and chronic obstructive pulmonary disease. The instrumental variable analysis found little evidence of a substantial increase in the risk of adverse outcomes, but that patients prescribed varenicline may be less likely to subsequently attend primary care than those prescribed NRT (risk difference=-17.5% 95% CI: -25.0% to -9.3%).

Conclusions: There was little evidence of a substantial increase in the risk of adverse outcomes in patients prescribed varenicline as part of their standard clinical care.

 

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A2

Jane Smith

University of Exeter

Informing the NHS Diabetes Prevention Programme: findings from the Community-based Prevention of Diabetes (ComPoD) trial

 

Jane R Smith, University of Exeter Medical School

Colin Greaves, University of Exeter Medical School

Janice L Thompson, University of Birmingham

Rod Taylor, University of Exeter Medical School

Matthew Jones, University of the West of England

Rosy Armstrong, University of Exeter Medical School

Sarah Coleman, University of Birmingham

Annie Griffin, University of Birmingham

Michele Kok, University of the West of England

Emma Solomon-Moore, University of Bristol

Charles Abraham, University of Exeter Medical School

 

Background: Implementation of the NHS Diabetes Prevention Programme (DPP) has begun and will roll out to the whole country by 2020 building up to 100,000 referrals per year.

Aims: The ComPoD study (www.isrctn.com/ISRCTN70221670) was a randomised, waiting list controlled trial across two sites (Exeter, Birmingham). It evaluated whether an existing community-based, voluntary sector-led diabetes prevention programme (one of four being adapted for use in the NHS DPP) was effective in modifying weight and other diabetes risk factors.

Methods:  314 overweight/obese adults with ‘pre-diabetes’ according to recent blood glucose testing were recruited via GP practices and randomised to receive the programme immediately (intervention) or after 6 months (control). Changes over 6 months in objectively-measured weight (primary outcome), physical activity, blood glucose, self-reported diet and health status were compared between groups. Maintenance of changes from 6-12 months was assessed in the intervention group only.

Results: 285 (91%) participants provided comparative 6 month follow up data, and 137 (87%) of the intervention group provided 12 month observational data. Detailed results will be presented and indicate significant but modest effects on weight loss and other weight-related outcomes comparable to those observed in a linked before-after evaluation of the programme (e.g. 1.7kg weight loss at 6 months). However, there were limited effects on other objective and self-reported outcomes. Examination of intervention delivery compared to NICE guidance and analysis of effects across population subgroups suggested ways in which implementation and effectiveness might be enhanced.

Conclusions: Robust, comparative evidence from our trial indicates that a UK-based real world diabetes prevention programme can be effective and informs adaptations and implementation in the context of the NHS Diabetes Prevention Programme.

 

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A3

Gemma Hammerton

University of Bristol

Low resting heart rate, sensation seeking and the course of antisocial behaviour across adolescence and young adulthood

Hammerton, G. ¹, Heron, J. ², Mahedy, L. ¹, Maughan, B. ³, Hickman, M. ⁴ & Murray, J.⁵

 

¹ Senior Research Associate, University of Bristol

² Senior Research Fellow, University of Bristol

³ Professor of Developmental Epidemiology, King College London

⁴ Professor of Public Health and Epidemiology, University of Bristol

⁵ Professor of Epidemiology, Universidade Federal de Pelotas

 

Aim: This study uses a large, prospective population cohort to examine whether the association between low resting heart rate (RHR) in childhood and the persistence of antisocial behaviour (ASB) from adolescence into adulthood is explained through sensation seeking.

Background: Low RHR is a robust biological correlate of ASB, however potential mechanisms have been largely unexplored. Sensation-seeking theory suggests that low RHR is a marker of low autonomic arousal, and therefore may be an unpleasant physiological state which leads those with a low heart rate to seek out stimulating activities, including ASB, in order to increase their autonomic activity to more optimal levels.

Methodology: Frequency of ASB was assessed repeatedly with young people from age 15 to 21 years in a population-based birth cohort (ALSPAC). A longitudinal trajectory was derived and showed ASB decreasing across adolescence before stabilising in early adulthood. RHR was recorded during a focus clinic at age 11 years, and sensation seeking was assessed at age 14 years using a modified version of Arnett’s Inventory of Sensation Seeking. Data were analysed using structural equation modelling in Mplus v7.4.

Results: After adjusting for confounders, there was evidence for a total effect of low RHR on initial ASB levels in mid-adolescence, which was almost entirely explained through sensation seeking. There was also evidence for an indirect effect of low RHR on final ASB levels in early adulthood via sensation seeking, that was not accounted for by confounders or initial ASB levels.

Conclusions: Low heart rate in childhood was associated with both levels of ASB in mid-adolescence and persistence into adulthood, and these associations were explained through sensation seeking. These findings indicate that interventions for ASB in those with a low heart rate should target sensation seeking and teach young people prosocial ways to increase their autonomic activity.

A4

Amoola Vusirikala

University of Bristol

Mid-life Social participation and Physical performance in old age: evidence from a British Birth Cohort

Vusirikala A¹, Ben-Shlomo Y², Morgan G³

¹Academic Foundation Doctor Year 2, School of Social & Community Medicine, University of    Bristol

² Professor of Clinical Epidemiology, SSCM, University of Bristol

³ NIHR Academic Clinical Lecturer in Public Health Medicine, SSCM, University of Bristol

 

Aim: To examine the association of social participation in mid-life with objective measures of physical performance in early old age.

Background: Previous studies among older adults have shown that social participation are related to adverse health outcomes such as disability, chronic conditions and mortality. However, these studies have had considerable limitations such as the use of self-reported measures of physical function and short follow-up times.  There is evidence that objective measures of physical function predict mortality and nursing home admission, so elucidating mid-life risk factors that can influence them may contribute to healthy ageing and will be useful for public health policymakers.

Methodology: The study uses data on approximately 1600 men and women from the National Survey of Health and Development. Social participation was summarised from items about being involved in a number of social group activities.  At 60-64 years, physical performance and strength were measured using four objective measures: grip strength, standing balance, chair rise time, and timed get-up-and-go (TUG) tests involving chair rise and walking speed. Analysis was conducted in STATA 14, using multivariable linear regression. 

Results: In the unadjusted analyses, individuals reporting the highest frequency of social participation at age 43 had faster chair rise, timed up-and-go (TUG) performance, longer standing balance, and - for females - stronger grip strength, when compared to those who reported low frequency participation. After adjustment of confounders including health conditions and socioeconomic status, there remained evidence of an association for chair rise (1.34 rep/min, 95% CI 0.36-2.31, p=0.007) and TUG performance (2.54 cm/s, 95% CI 0.34-4.74, p=0.02).Sensitivity analyses, with further adjustment for alcohol and smoking attenuated the association and were consistent with chance.

Conclusion:  Social participation in mid-life is associated with better physical performance in early old age though whether this reflects confounding or mediation by health behaviours is unclear. 

 

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B1

Mira Hidajat

University of Bristol

Equitable access to smoking cessation amongst older smokers: can we do better?

Hannah Jordan¹, Mira Hidajat², Jamie Brown³, Nick Payne¹, Jean Adams⁴, Martin White⁴, Yoav Ben-Shlomo²

 

Affiliations

1. Section of Public Health, School of Health and Related Research (ScHARR)

The University of Sheffield

2. School of Social and Community Medicine, University of Bristol

3. Clinical, Educational & Health Psychology, Division of Psychology & Language Sciences, Faculty of Brain Sciences, UCL

4. MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine

 

Roles

Concept and design: Jordan, Adams, Payne, Hidajat, Ben-Shlomo

Acquisition, analysis, or interpretation of data: Jordan, Brown, Payne, Hidajat, Ben-Shlomo

Statistical analysis: Hidajat, Ben-Shlomo

Writing the initial draft: Jordan, Hidajat, Ben-Shlomo

Critical review, commentary, revision: All authors

Study supervision: Ben-Shlomo, Payne

 

Aim: This study investigated the possibility of​age ​inequity in access to smoking cessation support in England ​by ​comparing older and younger smokers motivation to quit smoking and smoking cessation management by General Practitioners​ (GPs).

Background:  Although there is clear evidence of benefits of quitting smoking in older ages, several studies have found older smokers received less cessation support than younger smokers.

Methodology: We used data from the Smoking Toolkit Study, a repeated cross-sectional household survey from 2006 to 2015 (N=181,157).  Cessation behaviours were measured through quit attempts, smoking reductions, use of ​nicotine replacement therapies (NRTs)​ and NHS advice services. GP management was measured through self-reports of GP visits: smoking discussions and whether cessation aids (prescriptions/referrals) were given.  Exposure of interest is age, specifically to examine whether it is associated with cessation behaviours and access to smoking cessation therapies, controlling for gender, survey year, and socioeconomic status. We used multivariable logistic regression methods.

Results: Older smokers, despite being less dependent on nicotine and smoking fewer cigarettes, were less likely to attempt to quit and had less experience with NRTs than younger smokers.  This may reflect reduced motivation as older smokers were less likely to raise smoking as a topic in their GP consultations, with the exception of participants in the peri-retirement ages. Although GPs raise​d​ smoking as a topic equitably across all age groups, older smokers​ were ​less likely to be given referrals for NRTs (75+ versus 16-54 years; OR 0.70, 95% CI 0.56-0.89, p<0.01).

Conclusions: Opportunities to facilitate smoking cessation may be ​ being missed,​ but it is unclear whether this constitutes inequity​,​ lack of understanding about benefits of quitting even at an older age or older patient preferences​. Future qualitative work needs to explore these areas to help design the most appropriate interventions to reduce any inequity in access.

 

B2

Gemma Morgan

University of Bristol

Preventing disability using a physical activity intervention: findings from a pilot randomised controlled trial (RCT)

Morgan GS¹; Haase A²; Campbell R³; Ben-Shlomo Y⁴

¹NIHR Academic Clinical Lecturer in Public Health, School of Social and Community Medicine, University of Bristol

²Senior Lecturer in Exercise, Nutrition and Health, School of Policy Studies, University of Bristol

³Professor of Public Health Research, School of Social and Community Medicine, Bristol

⁴Professor of Clinical Epidemiology, School of Social and Community Medicine, Bristol

 

Aim: The study aim was to evaluate the feasibility of a definitive RCT of a theory-based physical activity (PA) intervention​ in older adults at risk of disability.

Background: Physical activity reduces the risk of disability in older adults but low activity in this population is extremely common. Self-determination theory (SDT) proposes that behaviour change occurs when an individual's psychological needs – for autonomy, competence, and relatedness - are met.

Methodology: 51 older adults at risk of disability were identified using the validated Short Physical Performance Battery (SPPB). Participants were recruited through primary care and randomly assigned to intervention - sessions with a PA facilitator (PAF) - or usual care. PAFs delivered sessions based on SDT over 6 months. Tests of physical function, objective and self-reported PA, quality of life, depression, motivation, and healthcare utilisation were taken at baseline and 6 months. A mixed methods process evaluation was nested within the trial.

Findings: Of 1​​884 postal invitations and 344 positive replies (18%), only 48 patients were eligible (14%). Responders were from less deprived areas than non-responders (Index of Multiple Deprivation 16.4 v 19.8, p<0.01). Opportunistic recruitment in GP waiting rooms was not effective. Participants and PAFs were enthusiastic about the intervention and there was evidence of promise - PAFs increased participants' motivation for PA. Specific behaviour change techniques were favoured. Unexpectedly and importantly, ​high prevalence of mental health issues was identified.

Conclusions: It is feasible to deliver an RCT of this intervention in this population. Support for older adults’ autonomy and feelings of competence were addressed in PAF sessions however more emphasis on relatedness and the beneficial role of social support networks is required. It is necessary to identify a more cost-effective method of recruitment and to consider how to manage those with complex mental health needs ​before commencing a full-scale trial.

 

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B3

Katie Currie

Bristol City Council

Health Inequalities, Risky Behaviours and Protective Factors in Wiltshire Adolescents: An Analysis of Secondary Survey Data

Katie Currie, Masters Student- UWE, Public Health Principal- Bristol City Council

 

Context: Adolescence is a point in the life course when young people are at risk of poor health outcomes and developing detrimental health behaviours that will affect their adult health.

Aim: To identify the prevalence of health risk behaviours (HRB), comparing young people (12-18yrs) in Wiltshire who are vulnerable (looked after children, SEND, young carers and military dependents) to those who are not vulnerable, and whether these behaviours are associated with protective factors.

Method: A secondary analysis of survey data (n=4129) compared 900 vulnerable young people and 3229 non-vulnerable young people. Differences between the two groups were assessed using Chi-square tests, and associations with possible protective factors were assessed using logistic regression (adjusting for confounding).

Findings: Vulnerable young people have a higher prevalence of smoking tobacco (15% vs 9%, p.0.00), using cannabis (7% vs 5%, p.0.03) and self-harming (16% vs 9%, p.0.00)monthly or more compared to the rest of Wiltshire adolescent population.  When analysing the whole population, health protecting factors each had a statistically significant relationship with at least one HRB, several had more than one association.  Whilst vulnerable young people and those in the rest of Wiltshire have many shared protective factors, there are also differences between the two groups. 

Discussion and Conclusion: There are shared protective factors across risk behaviours that can build on the resilience of a young person, impacting on their current and future health.  Therefore, we should focus our attention on promoting general health and wellbeing, not solely delivering specialist interventions targeted at specific risks. Further consideration should be given to identifying and promoting protective factors for vulnerable people as they have higher levels of HRB, and experience protective factors differently. 

B4

Matthew Hickman

University of Bristol

Evaluating the impact of opioid substitution treatment on mortality – a CPRD cohort study comparing community prescribing of buprenorphine and methadone in UK 

Matthew Hickman¹, Colin Steer¹, Kate Tilling¹, Aaron Lim¹, John Marsden², Tim Millar³, John Strang², Peter Vickerman¹, John Macleod¹

1 SSSM, University of Bristol

2 NAC, Institute of Psychiatry, Kings College

3 Division of Psychology and Mental Health, University of Manchester

 

Aim: We examine mortality risk for opioid dependent people prescribed methadone or buprenorphine in UK primary care and test the hypothesis that buprenorphine reduces mortality risk compared to methadone

Methods: Cohort study of patients prescribed methadone or buprenorphine for opioid substitution treatment (OST) 1998-2014 extracted from the Clinical Practice Research Datalink, comprising 11,033 patients, 26,546 OST episodes and 30,410 person years follow-up.  Poisson regression models estimated mortality incident rate ratios (IRRs) for all cause and drug related poisoning with interactions fitted between OST modality and treatment period, and propensity scores for being prescribed buprenorphine as Inverse Probability Weights. 

Results: The lowest risk period was from 4 weeks on treatment until treatment cessation: all-cause mortality (ACM) and drug related poisoning (DRP) rates of 0.98 and 0.29 per 100personyears respectively.  Patients on buprenorphine compared to methadone had lower ACM rate in each treatment period. The fully adjusted IRR was 0.04 (95% 0.015 to 0.17) and 0.17 (95%CI 0.12 to 0.24) for patients on burprenorphine compared to patients on methadone in the first 4 weeks of treatment and first 4 weeks out of treatment respectively.  DRP risk was lower during OST for patients prescribed buprenorphine compared to methadone: adjusted IRR 0.08 (95%CI 0.01 to 0.48) and 0.37 (95%CI 0.17 to 0.79) for first four weeks and rest of time on OST respectively.  Duration on treatment was shorter on buprenorphine than methadone. There was insufficient evidence that methadone or bupreneorphine reduce drug related poisoning in the population (weighted IRR 1.32 95%CI 0.47-4.57 and 2.15 95%CI 0.45-5.19) for methadone and buprenorphine respectively.

Conclusions: Buprenorphine lowers all cause and drug related poisoning mortality compared to methadone in the first four weeks of treatment.  The combination of short treatment duration and raised mortality risk after leaving treatment may reduce the protective benefit of OST in the population.  

C1

Micky Willmott

Decipher

Smoke responsibly: Student and staff beliefs about smoking in further education settings. Qualitative findings from a process evaluation.

Micky Willmott. Senior Research Associate. DECIPHer, School of Social and Community Medicine. University of Bristol.

Rebecca Langford. Senior Research Associate. DECIPHer, School of Social and Community Medicine. University of Bristol.

Adam Fletcher. Professor. DECIPHer, School of Social Sciences. Cardiff University.

 

Aim: This paper presents data collected during the process evaluation of a smoking prevention feasibility trial in Further Education (FE) institutions. It aims to describe FE students’ beliefs and behaviour regarding smoking and smoking prevention in FE contexts.

Background: Preventing young people from taking up smoking is vital to maintain and accelerate recent declines in smoking rates. Most prevention efforts have focused on schools with almost no research conducted in FE institutions, despite 44% of regular smokers indicating they started smoking aged between 16-19 years. 

Methodology:  Eleven student (n=69) and six staff (n=19) focus groups (FGs) were conducted in three FE institutions (two colleges, one school sixth form) in Wales between May and September 2015. FGs included between 2 and 13 participants selected using convenience sampling. FGs covered: views on student smoking behaviour; perceptions of the intervention; and its perceived impact on student and staff smoking behaviours. FGs were recorded, transcribed verbatim and analysed in NVivo 10. All transcripts were coded line by line using a framework developed and tested by MW and RL derived from research questions and emergent inductive codes.

Findings: Students and staff expressed liberal, non-interventionist views about smoking. Smoking was recognised as harmful but was seen as a personal choice; students felt jaded by anti-smoking messages.

Students used smoking behaviours to signify transition to adulthood; not by appearing grown-up, but by demonstrating their understanding of appropriate smoking behaviour e.g. protecting minors from second-hand smoke.

Organisational policies (e.g. a blanket smoking ban) which did not allow this demonstration of responsibility and autonomy led to tensions between students and staff.

C2

Catherine Falconer

Devon County Council

Patterns and correlates of active commuting in adults with type 2 diabetes: cross-sectional evidence from UK Biobank

Falconer, C¹; Cooper, A²; and Flint, E³

¹Specialty Registrar in Public Health, Devon County Council; ²Professor of Physical Activity and Public, NIHR Bristol Nutrition Biomedical Research Unit, University of Bristol; ³Assistant Professor in Population Health, London School of Hygiene and Tropical Medicine

 

Background: Adults with type 2 diabetes are typically characterised by low levels of physical activity and high sedentary time. Active commuting (AC) offers a potential strategy to counteract this and improve health. The AC behaviours of adults with diabetes are not well understood.

Aim: The aim of this study is to describe the AC patterns of adults with type 2 diabetes and describe how these relate to measures of physical activity and sedentary behaviour. Social, employment and environmental correlates of AC will also be explored.

Methods: A cross-sectional analysis of baseline (2006-2010) data from the UK biobank cohort was undertaken. Adults with type 2 diabetes who reported commuting behaviour were included in the sample (n=6,896). Outcome measures were physical activity expressed as minutes of moderate-to-vigorous activity (MVPA) and total MET-minutes, and sedentary time expressed in hours/day. Multivariate linear regression was used to investigate the association between commuting mode, and physical activity and sedentary time. Hypothesised confounders included distance from home to work, deprivation and age. Multivariate logistic regression was used to identify social, employment and environmental correlates of AC behaviour.

Results: AC was reported by 5.5% of participants with the overwhelming majority using the car to commute (80%). AC was associated with an additional 73 (95% CI 10.8, 134.9) and 105 (95% CI 41.7,167.2) weekly minutes of MVPA for males and females respectively. AC was also associated with reduced sedentary time (β -1.1 95% CI -1.6, -0.7hours/day for males and β -0.8 95% CI -1.2, -0.3 hours/day for females). Deprivation and distance from home to work were identified as correlates of AC behaviour.

Conclusions: Rates of AC are very low in adults with type 2 diabetes. However, AC offers a potentially behavioural sustainable solution to increasing physical activity and sedentary behaviour and should be encouraged.

 

C3

Rona Campbell

University of Bristol

Multiple risk behaviour in adolescence is associated with substantial adverse health and social outcomes in early adulthood: findings from a prospective birth cohort study

Professor Rona Campbell , Professor Matthew Hickman , Dr Ruth Kipping , Dr Michele Smith , Dr Theodora Pouliou , Dr Jon Heron 

^[1]Professor of Public Health Research, School of Social and Community Medicine, University of Bristol, UK.

^[1]Professor in Public Health and Epidemiology School of Social and Community Medicine, University of Bristol, UK.

^[1]Senior Research Fellow in Epidemiology and Public Health, School of Social and Community Medicine, University of Bristol, UK.

^[1] Research Statistician, School of Clinical Sciences, University of Bristol, UK

^[1] Research Officer, Administrative Data Research Wales, Swansea University, UK

^[1]Senior Research Fellow, School of Social and Community Medicine, University of Bristol, UK.

 

Aim: We sought to assess if engagement in multiple risk behaviours (MRB) in mid-adolescence is associated with deleterious health and social outcomes in early adulthood.

Background: Adolescents engage in new and changed behaviours such as substance use or reduced physical activity. Evidence is accruing that these health risk behaviours co-occur at a population level and cluster within individuals. There has, however, been less focus on what the cumulative impact of engagement in MRB might be even in the short term.

Methodology: 5591 young people enrolled in the Avon Longitudinal Study of Parents and Children provided data on 13 risk behaviours from the domains of physical inactivity, substance use, self-harm, sexual health, vehicle-related risk behaviour, and antisocial behaviour when aged 15 to 16. Logistic regression was used to examine any association between the total number of behaviours engaged in and rates of obesity, harmful alcohol use, problem gambling, anxiety, depression, trouble with the police and unemployment and lack of training at age 18.

Results: There was a strong association between multiple risk behaviour and all seven adverse outcomes. For each additional risk behaviour engaged in, the odds of having anxiety or being a problem gambler were 1.18 [1.12, 1.24] and 1.20 [1.13, 1.27] respectively, the odds for depression were 1.24 [1.17, 1.31], and the odds of getting into trouble with the police or of harmful drinking were 1.49 [1.42, 1.57] and 1.58 [1.48, 1.69] respectively. Adjustment for gender, parental socio-economic position, and maternal risk behaviours did little to alter the odds of these adverse outcomes. Confining analyses to adolescents not having experienced the adverse outcomes before age 15, to exclude reverse causality, also produced little change in odds.

Conclusions: Investment in interventions and environments that effectively prevent multiple risk behaviour is likely to produce improvements in adolescent health and wellbeing.

 

C4

Katrina Wyatt

University of Exeter

Connecting Communities: Creating the conditions for health in very low income communities

Wyatt, KM, Durie RH, Professor of Relational Health, University of Exeter Medical School

 

Aim:  To co-create the conditions in very low income communities for health.

Background: Poor health behaviours cluster in economically disadvantaged communities. Unlike traditional public health approaches which focus on trying to change particular behaviours, or the behaviour of individuals, in isolation, Connecting Communities [C2] takes a relational approach to co-creating the conditions which enable sustainable healthful behaviours to emerge.

Methodology: C2 is underpinned by complexity theory and starts from the premise that more of the same cannot deliver change on the scale that can make a genuine difference in health. Rather than beginning with a pre-defined problem, it is way of meaningfully engaging with communities to enable them to identify the issues or challenges which are most urgent in their neighbourhood. This process brings together residents and service providers who co-create potential solutions to these issues, and this process in turn radically transforms the ways in which services are delivered. As a consequence, often transformational health and social outcomes emerge within communities.

 

E1

Sean Cowlishaw

University of Bristol

Gambling problems in primary care: A cross-sectional study of general practices

Sean Cowlishaw, Lone Gale, Alison Gregory^, Jim McCambridge^, David Kessler

 

Background:  Primary care is an important context for addressing health-related behaviours, and may provide a setting for identification of gambling problems. AIM:To indicate the extent of gambling problems among patients attending general practices, and explore settings or patient groups that experience heightened vulnerability.

Design and Setting:  Cross-sectional study of patients attending 11 general practices in southwest England.

Method:  Adult patients (n = 1,058) were recruited from waiting rooms of practices that were sampled on the basis of population characteristics. Patients completed anonymous questionnaires comprising measures of mental health problems (e.g., depression) and addictive behaviours (e.g., risky alcohol use). The Problem Gambling Severity Index (PGSI) measured gambling problems, along with a single-item measure of problems among family members. Estimates of extent and variability according to practice and patient characteristics were produced.

Results:  There were 0.9% of all patients exhibiting problem gambling (PGSI 5+), and 4.3% reporting problems that were low to moderate in severity (PGSI 1-4). Around 7% of patients reported gambling problems among family members. Further analyses indicated that rates of any gambling problems (PGSI 1+) were higher among males and young adults, and more tentatively, within a student healthcare setting. They were also elevated among patients exhibiting drug use, risky alcohol use and depression.

Conclusion:  There is need for improved understanding of the burden of, and responses to, gambling problems in general practices, and new strategies to increase identification in order to facilitate improved care and early intervention.

 

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E2

Hein Heuvelman

University of Bristol

Gestational age at birth and risk of idiopathic intellectual disability: population based study

Hein Heuvelman research associate^{1 *}; Kathryn Abel professor ^{2, 3}; Susanne Wicks research associate ^{4, 5}; Renee Gardner associate professor ^{4, 5}; Edward Johnstone clinical senior lecturer  ⁶; Brian Lee associate professor ⁷; Cecilia Magnusson adjunct professor ^{4, 5}; Christina Dalman professor / senior physician ^{4, 5}; Dheeraj Rai consultant senior lecturer ^{1, 8}      

¹ Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, Oakfield House, Oakfield Grove, BS8 2BN, Bristol, UK                                                                       

² Centre for Women’s Mental Health, Manchester Academic Health Sciences Centre, Institute of Brain Behaviour and Mental Health, University of Manchester, 3^rd floor Jean McFarlane building, Oxford Road, M13 9PL, Manchester, UK

³ Manchester Mental Health & Social Care Trust, Chorlton House, 70 Manchester Road, M21 9UN, Manchester, UK

⁴ Division of Public Health Epidemiology, Department of Public Health Sciences, Karolinska Institute, Tomtebodavägen 18a, Widerstöma Huset, 171 77, Stockholm, Sweden;

⁵ Centre for Epidemiology and Community Medicine, Stockholm County Council, Tomtebodavägen 18a, Widerstöma Huset, 171 77, Stockholm, Sweden;

⁶Maternal and Fetal Health Research Centre, Manchester Academic Health Sciences Centre, Institute for Human Development, University of Manchester, St Mary's Hospital, Oxford Road, M13 0WL, Manchester, UK;

⁷ Department of Epidemiology and Biostatistics, A.J. Drexel Autism Institute, Drexel University School of Public Health, Philadelphia, PA, USA;

⁸ Avon & Wiltshire Mental Health Partnership NHS Trust, Jenner House, Langley Park, SN15 1GG, Chippenham.

 

Aim: Using data from the Stockholm Youth Cohort, we examined associations between gestational length and risk of intellectual disability without a common genetic cause.

Background: Preterm birth has been linked to intellectual disability and the role of post-term birth has been highlighted, but is less certain. As post-term birth may be avoidable by induction of labor, it is important to clarify whether these associations are likely to be causal.   

Methodology: We examined a cohort of 499,621 individuals living in Stockholm County between 2001 and 2011 and aged 4 to 17 years during that period. Using logistic regression models, we examined associations between gestational length and risk of intellectual disability. To allow stronger causal inference from our results, we examined a nested cohort of 8,034 outcome-discordant siblings to consider confounding from shared familial factors.

Results: Children who were born <37 or >41 weeks had higher risk of intellectual disability. Risk was greatest among those born at very early gestation (24 weeks: adjusted odds ratio=14.54 [95% CI=11.46–18.44]), lessening with advancing gestational age towards term (32 weeks: 3.59 [3.22–4.01]; 36 weeks: 1.79 [1.65–1.93]), after which it increased with advancing gestational age post-term (42 weeks: 1.16 [1.08–1.25]; 43 weeks: 1.41 [1.21–1.64]; 44 weeks: 1.71 [1.34–2.18]; 45 weeks: 2.07 [1.47–2.92]). Associations persisted in a nested cohort of matched outcome-discordant siblings, suggesting they were robust against shared familial confounders. Risk of intellectual disability was greatest among growth-restricted children, especially when birth occurred before or after term.

Conclusions: Delivery at non-optimal gestational age at either extreme was associated with a greater risk of intellectual disability. The potential causal mechanisms by which post-term birth might incur risk of intellectual disability, and whether interventions such as induction of labour can prevent intellectual disability, need to be examined in future research.

 

E3

Frank de Vocht

University of Bristol

A natural experiment combined with a novel statistical method to evaluate the impact of local alcohol licensing on health and crime.

Frank de Vocht^1,2, Kate Tilling^1,2, Triantafyllos Pliakas^1,3, Colin Angus^1,4, Matt Egan^1,3, Alan Brennan^1,4, Rona Campbell^1,2, Matthew Hickman^1,2

¹ NIHR School for Public Health Research

² School of Social and Community Medicine, University of Bristol, Bristol, UK

³ Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.

⁴ ScHARR, School of Health and Related Research, University of Sheffield, Sheffield, UK.

 

Aim: This study aims to estimate the causal impact of a change in local alcohol licensing policies on public health and crime using a natural experiment design.

Background: Variation in local implementation of alcohol licensing policies, including cumulative impact zones (CIZ), is associated with weak evidence of any public health improvement. However, this local and temporal variation enables the design of natural experiments which can provide stronger evidence of a causal effect.

Methodology: Home Office licensing data were linked to 2009-2015 alcohol-related hospital admissions, violent and sexual crimes, and anti-social behaviour rates. Intervention areas were local areas where a CIZ and increased licensing enforcement were introduced in 2011 (n=5), while control areas were those where neither were present throughout 2009-2015 (n=86). Bayesian structural time-series combined with spike-and slab priors were used to create post-intervention synthetic time-series based on weighted pre-intervention time trends in all control areas. Intervention effects could then be calculated from differences between measured post-intervention trends and expected trends in synthetic time-series.

Results / Findings: The introduction of a CIZ and simultaneous increase in licensing enforcement intensity was associated with an average reduction in alcohol-related hospital admissions of 6% [95% Bayesian Credible Intervals (BCI): -13%, 0%] and to lesser extent with a reduction in violent crimes, especially up to 2013 (-5% [95% BCI -11%,1%]). There was weak evidence of a reduction in sexual crimes up 2013 as well (-8% [95% BCI -21%, 5%]), but insufficient evidence of an effect on anti-social behaviour; the latter as a result of known changes in reporting.

Conclusions / Recommendations: Moderate reductions in alcohol-related hospital admissions and violent and sexual crimes were associated with introduction of local alcohol licensing policies. This novel methodology holds promise for use in other natural experiments in public health but relies upon stable trends prior to the intervention.

E4

Moses Ikpeme

University of Bristol 

Investigating Inequalities in Paediatric Burn Injuries in England: Findings from Analyses of Hospital Episodes Statistics (HES) data from 2009-2015

Ikpeme, M¹, Emond, A², Mytton, J³ and Hollen, L⁴

1. Postgraduate Researcher, Centre for Child and Adolescent Health, University of Bristol, 2. Professor in Child Health, Centre for Child and Adolescent Health, University of Bristol, 3. Associate Professor, Centre for Child and Adolescent Health, University of West of England, Bristol, 4. Senior Research Associate, Centre for Child and Adolescent Health, University of Bristol

 

Aim: To outline observable inequalities in paediatric burn admissions in England from 2009-2015.

Background: Following findings from a systematic review of 20 years (1995 to 2015) of available published research on paediatric burn/scald epidemiology in “Western-like” high income countries; being younger, male, of minority/indigenous ethnicity, deprived or staying in urban settings etc. was associated with increased risk of burn injuries. These findings were used to investigate the association between some socio-demographic factors and burn admissions in the Hospital Episodes Statistics (HES) database.

Methodology:  40,172 burn cases were identified with 36,080 being primary burn admissions. Descriptive analyses involved comparing the characteristics of children admitted for burns with the general paediatric population from the 2011 census. For multivariable analyses, a comparative group was created from a 1% sample of all other paediatric admissions from 2009-2015 (n= 124,841). Analyses were undertaken using Stata 14. Adjustment was made for individual (age/sex), family (ethnicity) and environmental (index of multiple deprivation (IMD) and rural/urban residence) factors. Variables of interest were 82% to 100% complete.

Results: Most burn admissions occurred in the North West region (22%), West Midlands (15%) and London (14%) respectively. Children in the most deprived quintile (5^th quintile) had highest odds for burn admissions than “other conditions”, OR= 1.75(95% CI: 1.68-1.83). After adjusting for confounders and co-variates, AOR=1.55(95% CI: 1.48-1.63). Black/Black British children had the highest OR for burn admissions, OR= 1.59(95%CI: 1.51-1.67), AOR=1.50(95% CI: 1.42-1.59).  Children from urban areas had higher odds of burns admissions, OR= 1.30(95% CI: 1.26-1.35), AOR=1.11(95% CI: 1.06-1.15). The strongest co-variate effect was observed in the 0-4 age group (AOR=1.99 [95% CI: 1.92-2.07]).

Conclusions: These findings provide brief insights of the impact of socio-demographic factors on burn admissions in children aged 0-15 years in England. These will assist in identifying groups more at risk for suitable interventions and aid preventive measures overtime.

 

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F1

Sarah Bird

Plymouth City Council

A new frontier in smoking cessation: qualitative interviews with vaping shop staff in the South West

Bird, S, Specialty Registrar in Public Health, Plymouth City Council

 

Aim: This qualitative study used semi-structured interviews to explore the knowledge, experiences and practices of specialist vaping shop staff in the South West.

Background: E-cigarettes are increasingly popular as a stop smoking device. Research is ongoing to understand the health effects of the products, but Public Health England has estimated they are at least 95% safer than tobacco and can be encouraged as a harm reduction approach.  This is the first known study to examine the role of retailers in helping people switch to e-cigarettes.

Methodology: Interviews were undertaken with 12 staff (seven male and five female, ages 22 to 56), including managers and sales assistants, in five shops across the South West. Participants were recruited purposively by age, gender, job role and smoking/vaping status. Mean interview duration was 36 minutes (27 - 66 minutes). Data was thematically analysed using the behaviour change wheel (BCW) theoretical framework to understand how staff helped smokers switch to vaping.

Findings: All participants were ex-smokers and current vapers. Personal experience played an important part in their day to day role. The main BCW intervention types used in customer interactions were Enablement, Training, Modelling and Persuasion. Staff provided ongoing technical and social support to customers to help them through the vaping learning curve. They reported the majority of their customers were smokers wanting to quit tobacco, and were highly motivated to help them and to work more closely with health professionals. There were often fluid boundaries between staff, customers, and the wider vaping community.

Conclusions: Staff in specialist vaping shops are playing an important role in helping people quit smoking. There is evidence of behaviour change techniques being used to support customers. Health professionals should work more closely with vaping staff to maximise the potential for e-cigarette harm reduction, and minimise associated risks

 

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F2

Alexa Gainsbury

Devon County Council

Parents' experience of NCMP written feedback in Cornwall: a qualitative analysis.

Lex Gainsbury, Specialty Registrar in Public Health, Devon County Council

 

Aim: This study aimed to explore parents in Cornwall’s experience of receiving routine feedback from the National Child Measurement Programme (NCMP) regarding their child’s weight and corresponding weight status. It aimed to contribute a qualitative perspective that explored how social contexts may help shape parents’ experiences of the NCMP and their perceptions of childhood weight.

Background: Several studies have found that NCMP feedback has limited impact on behaviour because it has been ineffective in supporting parents to accurately perceive their child’s weight status and the corresponding risks. Studies found parents tended to disregard overweight feedback as it was incongruous with their existing perceptions which underestimated weight and weight-related health risks. 

Methodology: 20 parents in Cornwall participated in four semi-structured focus groups and two one-to-one interviews. Thematic analysis was used to develop a narrative of emergent themes in order to reflect parents’ experiences of feedback and explore some of the social influences that shape that experience.

Results: This study found that participants tended to recall negative emotions in association with overweight feedback. Participants often rejected overweight feedback as lacking in credibility and considered NCMP communication to be targeting parents other than themselves. Participants’ social groups supported recipients of overweight feedback by reassuring them their child’s weight status was inaccurate, further legitimising their decision to dismiss feedback.

Conclusions: Despite some limitations, this study provides an insight into parents in Cornwall’s experience of NCMP feedback, including how they relate to and understand that experience within a social context. By doing so it makes a unique contribution to the existing body of evidence. Recommendations for practice arising from the study included developing a consistent approach to measuring childhood obesity risk across health agencies and further effort to raise parents’ awareness of childhood obesity and obesity prevalence through moderate examples of excess weight within media and health promotion literature.

 

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F3

Liam Mahedy

University of Bristol

Alcohol use and later working memory in adolescence: Findings from a large population-based birth cohort

Dr Liam Mahedy¹, Dr Suzanne Gage², Dr Gemma Hammerton³, Dr Jon Heron⁴, Professor Matthew Hickman⁵, Professor Matt Field⁶, & Professor Marcus Munafò⁷

¹Senior Research Associate, School of Social and Community Medicine, University of Bristol

²Senior Research Associate, School of Experimental Psychology, University of Bristol

³Senior Research Associate, School of Social and Community Medicine, University of Bristol

⁴Senior Research Fellow, School of Social and Community Medicine, University of Bristol

⁵Professor in Public Health and Epidemiology, School of Social and Community Medicine, University of Bristol

⁶Professor of Psychology, Department of Psychological Sciences, University of Liverpool

⁷Professor of Biological Psychology, School of Experimental Psychology, University of Bristol

 

Aim: This study sought to examine whether alcohol use during adolescence was associated with deficits in later working memory (WM) using a large UK prospective birth cohort.

Background: Although the majority of neuropsychological, brain imaging, and animal studies have suggested an adverse association between alcohol use and WM in adolescents, evidence from population samples using prospective designs is lacking.

Methods: We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to investigate the association between alcohol use (i.e., heavy typical drinking, frequent drinking, and regular binge drinking) at age 15 years and WM at age 18 years, assessed using the N-back task. Data were available on n = 3,351 participants for the 2-back version of the task and n = 3,319 participants for the 3-back version. Differential dropout was accounted for using multiple imputation and inverse probability weighting. Adjustment was made for multiple potential confounders.

Results: There was no evidence of an association between alcohol use at age 15 years and WM performance on the 2-back task at age 18 years when adjusting for potential confounding variables, including weekly smoking status. Regarding WM performance on the more resource-intensive 3-back task, we found evidence of an association between regular binge drinking at age 15 years and poorer WM (i.e., lower d' scores)at age 18 years (b = -.19, 95% CI = -.34 to -.05, p = .01), after adjusting for confounding variables, including weekly smoking status.

Conclusions: We find modest evidence of an association between regular binge drinking and impaired WM in mid to late adolescence. These findings have clinical and public health implications, as interventions aimed at delaying the onset of drinking might be effective in reducing impairments in WM.

 

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F4

Emma Anderson

University of Bristol

Paediatric respiratory tract infection surveillance: a community-based feasibility inception cohort study

Ms Emma C. Anderson, NIHR Health Protection Research Unit in Evaluation of Interventions, School of Social and Community Medicine, University of Bristol, Bristol

Dr Suzanne Marie Ingle, NIHR Health Protection Research Unit in Evaluation of Interventions, School of Social and Community Medicine, University of Bristol, Bristol

Dr Peter Muir, Public Health England, Specialist Virology Centre, Bristol

Dr Charles R. Beck, 1 Field Epidemiology Service, Public Health England, Bristol; 2 School of Social and Community Medicine, University of Bristol; 3 NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol

Dr John Peter Leeming, North Bristol NHS Trust, Bristol Centre for Antimicrobial Research and Evaluation (BCARE), Bristol

Dr Joanna Kesten, Collaborations for Leadership in Applied Health Research & Care in the West (NIHR CLAHRC West); NIHR Health Protection Research Unit in Evaluation of Interventions, School of Social and Community Medicine, University of Bristol, Bristol

Dr Christie Cabral , School of Social and Community Medicine, University of Bristol, Bristol

Professor Alastair D. Hay, NIHR Health Protection Research Unit in Evaluation of Interventions, School of Social and Community Medicine, University of Bristol, Bristol

 

Background: Much epidemiological research into respiratory tract infection (RTI) is conducted at the point of healthcare consultation, leaving the community burden, microbiology, duration and proportion consulting unknown.

Aim: This study sought to: 1) establish the feasibility of recruitment and retention to a paediatric RTI community surveillance study, with syndromic and microbiological data collection; and 2) estimate symptom duration and primary care consultation rates.

Methodology: Children (3 months £ 14 years) and their parents/carers were recruited via GP letters. Parents provided baseline data (including household demographics) online, and responded to weekly emails to confirm absence/presence of new RTI symptoms. Once symptomatic, parents provided daily symptoms data online. Research nurses visited to collect clinical examination data and nasal and saliva swabs. Parents took same day (symptomatic) and subsequent (asymptomatic) swabs. Consultation details and history were collected from primary care medical notes.

Feasibility was assessed by recruitment and retention rates (descriptive). Analysis of duration (Kaplan-Meier survival estimates) and consultation rates (descriptive) were restricted to first RTI per family to avoid clustering issues.

Results: 10,310 children and their parents/carers were invited. 485 (4.7%) were recruited (baseline completed) from 331 families, reporting 346 new onset RTIs (in 259 children; 206 families), with 88.7% (of 346) completion (parent-reported symptom resolution). Research nurses conducted 200 home visits and collected 195 symptomatic swab sets. Restricting to first RTI per family with symptoms reported (N=197), 90% RTIs resolved by day 23 and 8.1% consulted once/more. Participating parents had higher education, lower deprivation and younger children than those invited who did not participate.

Conclusions: Recruitment and retention into prospective community paediatric RTI surveillance with detailed symptom and sequential microbiological sampling is feasible. Our novel findings are: 1) consultation rates percommunity illness, and 2) community RTIs show similar duration to RTIs in consulting populations. Results are limited by sample representativeness.

This page was last updated February 27th 2017 (9 years ago)