Summary of #PHTwitJC 25: Alcohol price and drinking behaviour

alcOn Thursday 23rd May #PHTwitJC discussed the following paper:

A C Wagenaar et al (2009) Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies, Addiction, 104, 179–190 PDF

The full transcripts can be found on our archive page, however I’ve tried to summarise some of the key debates below.

1 – Were the aims of this study clear?

Although we all understood what that authors were hoping to achieve in this study, it was noted that the aims were not explicitely stated by the authors.  An important observation was made by @DotBirch:

@PHTwitJC as often seen with sys revs – the aim is in the abstract but not explicit in the paper (although I am fast
reading!) #PHTwitJC

@rebeccahams noted that the target population was not clearly defined.  Also, some commented that the outcomes were complex and not clearly defined (e.g. the authors did not explain how they were measuring drinking behaviour).  For example @rebeccahams tweeted:

#PHTwitJC my concern was about the difference in alcohol intake/attitudes in different countries and how that might affect pricing polices

2 – Was the systematic review comprehensive?

It was noted that the authors had not followed PRISMA guidelines for reporting methods of systematic reviews.  For example @dotbirch tweeted:

@PHTwitJC missing: flowchart and summary table? would have made reading much easier #PHTwitJC

@Fibigibi13 added:

@dotbirch @PHTwitJC #PHTwitJC And would have reduced the need to miss out detail in a lengthy narrative. (If word limits are an issue).

Overall we agreed that the review was comprehensive from what was written, but noted that the presentation of such information could’ve been improved through abiding to the PRISMA guidelines.

3 – Were any adjustments made for study size or quality?

This wasn’t very clear.  There was no information on data extraction nor quality assessment, and although some information was provided it was laid out in the narrative text rather than in tables or graphs.

@PHTwitJC #PHTwitJC YES!!! I found it very difficult to read being embedded in the text. Tables, charts, graphs, please!
@Fibigibi13 I would echo this feedback – find formulae hard to judge, but charts / graphs much easier to understand and interpret #PHTwitJC

As @DotBirch noted, adjustment for study size was done:

@PHTwitJC they have checked homogenieity and used both i and Q tests would take into account study size #statsnightmare #PHTwitJC

4 – Do you believe the results? Could anything else explain these findings?

The results of the paper show a strong statistically significant association, and can be summarised as follows:

@PHTwitJC however the results are #lush #PHTwitJC

@KateT_health tweeted:

@PHTwitJC I’m not totally confident in that given the elisions etc and lack of clarity in data. But I’d like to think it’s right! #PHTwitJC

Some further information would be useful to be able to more fully interpret these results.  Suggestions included controlling for potential confounders such as: general living costs, GDP, sub-group analysis… and looking at potential bias, e.g. definition and measures of ‘drinking behaviour’.

5 – What implications do the findings have for public health practice & policy?

The results of the paper suggest a strong association between alcohol pricing and drinking behaviour, which adds to the evidence that a population-level intervention for minimising alcohol misuse.  @DotBirch suggested:

@PHTwitJC i hope cameron reads it and does a U U turn on minimum pricing! #PHTwitJC

…to which @matandbec agreed:

@PHTwitJC I’ll raise a glass (containing no more than 3-4 units) to that #PHTwitJC

Following the lively discussion and debate we reflected upon the importance of communicating key messages from research, as well as being transparant in the methods used to derive at those messages.  As @PHTwitJC tweeted:

Interesting to reflect not just on what the results show and what that means, but how key #PublicHealth messages are communicated #PHTwitJC
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Time To Change stigma and discrimination: evaluation results

Mental health is an important public health topic. Mental health problems constitute a large proportion of the worldwide burden of disease; therefore establishing services for prevention and treatment according to need are priority areas for public health.

It is increasingly being recognised that both mental and physical health concerns should be treated with equal importance (parity of esteem).  However this is often easier said than done, as mental health is largely stigmatised and many people with mental health issues face discrimination.

You may recall that in April we critiqued a paper which was part of a series of evaluation papers from the Time To Change campaign.

I did a summary blog for The Lifestyle Elf on all seven of the Time To Change evaluation papers, and thought I would share it with you all.  I leave you with a link to my blog below, and a cartoon strip from the Time To Change campaign. Enjoy!

My blog: Time To Change stigma and discrimination: evaluation results

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#PHTwitJC 25: Does alcohol price affect drinking behaviour?

On Thursday 23rd May at 8pm #PHTwitJC will be discussing this paper:

A C Wagenaar et al (2009) Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies, Addiction, 104, 179–190 PDF

Why is alcohol a public health issue?

The misuse of alcohol – whether as chronically heavy drinking, binge-drinking or even moderate drinking in inappropriate circumstances (e.g. operating machinery, on medication) – not only poses a threat to the health and wellbeing of the drinker, but also to family, friends,  communities and wider society through such problems as crime, anti-social behaviour and loss of productivity. It is also directly linked to a range of health issues such as high blood pressure, mental ill-health, accidental injury, violence, liver disease and sexually transmitted infection.

There are various options to try and reduce alcohol misuse including individual approaches (such as support services to identify and help people with alcohol related problems), education (such as the Know Your Limit, and Change4 Life ‘sneaky drinks’ adverts), through to licensing, regulation and legislation.  Setting a minimum-price for alcohol has recently been implemented in Scotland (50 p per unit), and is currently being considered as an option to reduce alcohol misuse in the rest of the UK.

For further information:

Paper Summary:

  • Method: The authors did a systematic review of studies which examined the relationship between measures of beverage alcohol tax or price level, and alcohol sales or self-reported drinking (n = 122 studies found)
  • Analysis: Partial correlations were calculated for each major model or subgroup reported within each study.  Random effects models were used to combine studies for inverse variance.
  • Results: Meta-analytical results showed a relationship which was statistically significant (p<0.001). Aggregate-level r = -0.17 for beer, -0.30 for wine, -0.29 for spirits and -0.44 for total alcohol.

The authors concluded:

A large literature establishes that beverage alcohol prices and taxes are related inversely to drinking.  Effects are large compared to other prevention policies and programs. Public policy that raise prices of alcohol are an effective means to reduce drinking

Discussion Points:

All are welcome to join the discussion at the Twitter Hashtag #PHTwitJC. If you have not joined a Twitter chat before, please see the ‘about’ tab above for some tips.

  1. Were the aims of this study clear? (consider the population, outcome measures, intervention)
  2. Was the systematic review comprehensive? (consider research designs included, inclusion and exclusion criteria, would all relevant studies have been identified?)
  3. Were any adjustments made for study size or quality? (if appropriate)
  4. Do you believe the results? Could anything else explain these findings? (Consider whether the results are due to chance, bias, confounding or the truth?)
  5. What implications do the findings have for public health practice & policy? Do you agree with the authors conclusions?
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#PHTwitJC 25: Cast your votes!

public health

Public health: it takes more than just good evidence to change behaviour

Public health is everywhere. Whenever I read the paper, turn on the news, there is always something health-related to be debated and discussed.  And this is one of the many reasons why I enjoy working in public health – theres always something going on!

This month I have selected a range of papers which I feel reflect some current public health debates, in the hope that you will join me on Thursday 23rd May at 8pm BST for a journal club discussion of the winning paper.

So which topic would you most like to debate? …Cast your vote below!



  • A C Wagenaar et al (2009) Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies, Addiction, 104, 179–190 PDF
  • L R Smith et al (2013) Assessing the short-term outcomes of a community-based intervention for overweight and obese children: The MEND 5-7 programme, BMJ Open. 2013;3 PDF
  • J Waller et al (2013) Women’s responses to information about overdiagnosis in the UK breast cancer screening programme: a qualitative study, BMJOpen 2013; 3 PDF
  • R Polosa et al (2011) Effect of an electronic nicotine delivery device (e-Cigarette) on smoking reduction and cessation: a prospective 6-month pilot study, BMC Public Health 2011, 11 :786 PDF
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Summary of #PHTwitJC 24 Chat – Mental health discrimination: impact of Time to Change

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Mental health discrimination: impact of Time to Change

On 22nd April 2013, Public Health Twitter Journal Club #PHTwitJC discussed a research paper on experiences of discrimination among mental health service users in England, which was part of the evaluation of a major campaign to tackle mental health stigma.

  1. We discussed this paper by Corker et al (2013). An introduction to the paper with some background is available on the Public Health Twitter Journal Club (PHTwitJC) blog page. If you want any further information about PHTwitJC you’ll also find it on the blog.   A full transcript of the chat can be accessed here or in the blog Archive.

    The paper reports on one of the strands of evaluation for the Time to Change project:
  2. Our discussion

  3. Question 1. Does the study address a clearly focused question/issue? Is the study design appropriate to address this?

    Participants agreed that there was a clear focus for the study, but it was felt that this was a difficult question to address:
  4. Yes, focused Q: did @TimeToChange achieve a 5% reduction in discrimination towards ppl using mental health services #PHTwitJC
  5. #phtwitjc think it was a clear aim, although not an easy one to design a study to evaluate maybe.
  6. @PHTwitJC study aim is clearly aligned to @TimetoChange target, however study design doesn’t determine if #TTC reps for reduction #PHTwitJC
  7. The Time to Change (TtC) programme identified three major sets of goals and outcomes, the first of which was:

    significantly increased public awareness of mental health (an estimated 30 million English adults would be reached), a 5% positive shift in public attitudes towards mental health problems and a 5% reduction in discrimination by 2012.
    As @carotomes and @Mental_Elf pointed out, the study was explicitly linked to the latter target, although it would be difficult to identify a causal link (this is fully acknowledged in the study).
    The study design was a cross-sectional telephone survey (the ‘Viewpoint’ study) with people identified as having recently used specialist mental health services. The survey was repeated, using different NHS trusts from across England, in 2008 (baseline), 2009, 2010 and 2011.
    Participants felt that this design had limitations, but was justifiable for pragmatic reasons (cost and scale of alternatives such as a cohort design):
  8. @duncautumnstore yes, exactly, was thinking all the way through it that using prospective cohort might have solved some issues… #phtwitjc
  9. @duncautumnstore but then also might create more issues as not everybody wld have contact with MH services in any given year. #phtwitjc
  10. @rorymorr prob best design though the probs you say and £s. Always a little wary of drawing too much from repeated cross section #PhtwitJC
  11. 2. Were the methods of selecting and recruiting to the study adequately described; were they appropriate?
  12. Summary of the design: Five NHS mental health trusts were selected for each round of the survey. They were selected to reflect the socio-economic spectrum (e.g. using index of deprivation quintiles) across England. Staff within each Trust used their records to identify a random sample of all adults (aged 18-65) with a mental health diagnosis who were in receipt of ongoing treatment (contact with specialist services within the past 6 months). Clinical staff within the Trust then checked and screened the sample.  Information packs were mailed out to the sample, and telephone interviews were scheduled after receipt of consent forms.

    The use of existing health service data to identify participants was regarded as a positive factor:
  13. @PHTwitJC yes, thought it was smart – nice to see NHS routine data being put to good alternative use too! #PHTwitJC
  14. However, journal club participants noted that slight alterations were made for each repetition of the study, in addition to the use of different geographical areas. For example, the sample size doubled after the first year as a result of disappointing response rates; after 2008, information packs were provided in community languages; in 2011 only, an incentive (£10 voucher) was offered for participation.
  15. @carotomes @duncautumnstore a lot of interpretive prblms stem frm slight changes that cld happen to sampling frame each year #phtwitjc
  16. @rorymorr @duncautumnstore true. Would it be better to stick with same areas every year? (Risk bias?) #PHTwitJC
  17. These changes were seen as justifiable in the main: the aim was to enhance recruitment and avoid the study being underpowered.

    Different trusts were used to enhance the generalisability of the findings; we discussed this strategy:.
  18. Did selecting different trusts/ areas each year make it more representative of popn? Any probs doing that?
  19. @PHTwitJC interesting q! Are there any systematic differences between trusts/areas? I’m not sure. #PHtwitJC
  20. @PHTwitJC initial thought was danger that using same MH trusts would make them aware of being measured >> inaccurate picture #PHTwitJC
  21. A specific aspect of sampling, clinical staff screening out service users who were ‘judged to be at risk of distress’, was queried as a possible source of bias:

  22. @PHTwitJC as opportunity exists there for screening out ‘problem’ service users who cld have had the worst discrim experiences #phtwitjc
  23. More information on the criteria used was requested, in order to assess the subjectivity of this approach.

    @carotomes commented that there is always likely to be some recruitment bias in mental health studies, because of stigma preventing some from using services at all.
  24. Question 3. Was the sample adequate & representative of the population (mental health service users in England)?
  25. Table 1 of the article outlines the participant characteristics for each year of the study: numbers; gender; age; ethnicity; employment status; diagnosis; and whether they had received involuntary treatment. Numbers recruited in the first year were much lower than in subsequent years (537 compared to ~1000 in the later years), probably due to changes in the sampling and recruitment process (mentioned above).   It was felt that the low response rates (8-11% of the sample) were not particularly surprising in the context of generally expected phone survey response rates, plus the characteristics of the target sample.

    Representativeness of the other characteristics varied:
  26. @PHTwitJC participant gender and age looked well balanced, however Dx employment and ethnicity less so #PHTwitJC
  27. Some of these differences were taken into account in the analysis:
  28. @carotomes @PHTwitJC I think they say they weighted sample by age, gender, ethnicity… but other stuff more free to vary #PHTwitJC
  29. However, some were not explicitly – we picked out employment status and mental health diagnosis as differences that may have impacted on the results in unknown ways. Our discussion particularly focused on the differences in proportions of participants with specific mental health diagnoses across the years:
  30. @PHTwitJC in particular, bipolar % reduces in sample as depression % increases – could be those with depression less likely to 1/1 #PHTwitJC
  31. @carotomes @PHTwitJC yes, good point, didn’t notice that… also the ‘other’ dx increases quite a lot 08->11. #PHTwitJC
  32. @PHTwitJC I feel variation in clinical Dx between years is problematic. Different Dx >> different discrimination… #PHTwitJC
  33. It was suggested that a statistical model could have been developed to take account of all of these differences. It would also have been useful for the reader, to see a breakdown of the results (discrimination experiences) by diagnostic group, which is not offered in the paper.
  34. Question 4. Is the survey tool (DISC) likely to measure appropriately; is it a valid tool?  

    The Discrimination and Stigma Scale (DISC) was used for the survey (more information in the paper, and background here). It was noted that the results as represented in the paper, lost the nuances of the scale. Results were presented in a binary (experienced stigma in this area of life in the past year or not), rather than reflecting the scale which indicates frequency:
  35. @PHTwitJC use of DISC was fascinating! Turning the answers into a yes/no, lost a load of data on frequency of discrimination! #PHtwitJC
  36. @duncautumnstore yes thought that was weird, but not familiar with DISC so was ‘hmm, well if you are sure that’s ok to do..!’ #phtwitjc
  37. @rorymorr not familiar either: seems to change the research question to reduction in % people discriminated, rather than amount #PHTwitJC
  38. Question 5. Results: are these presented adequately so that the reader can assess their validity & reliability? Are they adequately explained (any confounders)?
  39. Discussion continued from the previous point, relating to the nature of the 5% target and the research question:
  40. @duncautumnstore would it have been useful to at least see the ‘amount’ results as well as the ‘ever experienced’ ones? #PHTwitJC
  41. @PHTwitJC it depends on how you want to measure progress towards a 5% reduction in discrimination though: people or overall amount #PHTwitJC
  42. Table 2 lays out participants reporting types & areas of discrimination; direction of change between 2008 and ’11. This was picked out as unhelpful for a full interpretation of the results, because of a selectivity in what was presented:
  43. found it really lousy that table 2 doesn’t have each year of data, only 08 and 11 – you can’t assess trend or variability easily #phtwitjc
  44. #phtwitjc which makes me worry that it is reported like that because the numbers for other years are all over the place (cynical, I am)
  45. @rorymorr there are no excuses really, plenty of room for more data if they squidged up the columns… #PHTwitJC
  46. The main finding of the study was that there was a statistically significant drop in discrimination experiences over the period, but that it fell short of the 5% target.  We discussed whether this finding was valid / significant.
  47. OK authors claim a statistically significant reduction in discrim experiences, do the data support that? #PHTwitJC
  48. Sampling frame differences, and the lack of data presented that took into account differences, were seen as problematic:
  49. @PHTwitJC unsure results are convincing that experiences of discrimination have reduced – stats not accounted for Dx, employment.. #PHTwitJC
  50. The ‘5% reduction’ target that is being evaluated was itself discussed and felt to be somewhat arbitrary and ambiguous:
  51. @PHTwitJC @duncautumnstore I would like to know where 5% target came from! What was rationale? #PHTwitJC
  52. @carotomes @PHTwitJC good q! Was it programme designers or political aspiration – 5% is the smallest large number?… #PHTwitJC
  53. @duncautumnstore @PHTwitJC was it because it sounds good, 5% “feels” like it would’ve made a difference? Or more scientific?! #PHTwitJC
  54. 6. Overall evaluation / implications for policy and practice

  55. Overall the journal club participants were positive about the study, although it had limitations; and found it a very interesting attempt to evaluate an ambitious population level intervention. We agreed that the evaluation project as a whole (reported within the same journal special issue) was innovative in its multistranded design and deserved approaching as a whole, in order to properly appreciate the impact of the TtC intervention.
  56. @PHTwitJC study highlights the difficulty in measuring discrimination – but makes improvement on previous studies #PHTwitJC
  57. @PHTwitJC does an ok job but a lot of limitations… I think gets a ‘maybe’ for TTC impact on discrimination #phtwitjc
  58. TtC is a fascinating attempt to approach #MH from a mass /PH point of view – measurement always be difficult#PHTwitJC
  59. @PHTwitJC quite hard to directly link the change to the campaign as I think @carotomes pointed out earlier, but… 1/2 #PHTwitJC
  60. @PHTwitJC this isn’t the only evidence. Think all the papers together are a good eg of a multistranded evaluation! 2/2 #PHTwitJC
  61. @PHTwitJC #TTC exciting and groundbreaking campaign; looking forward to reading the other studies! #IHeartPublicMentalHealth #PHTwitJC
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#PHTwitJC24: Mental health service users: changes in experiences of discrimination and Time to Change

Our live journal club chat will take place on Monday 22nd April at 8.00-9.00 pm UTC (UK time). To follow and participate, search for our hashtag #PHTwitJC on Twitter, and remember to use the hashtag if you want to contribute. If you’ve never joined a Twitter chat before, please see the ‘About ‘ tab above for some tips. Absolutely anyone is welcome to join in; and we welcome ‘stupid’ questions (there is of course, no such thing).

The paper we will be discussing is:

Corker E, Hamilton S, Henderson C, Weeks C, Pinfold V, Rose D, Williams P, Flach C, Gill V, Lewis-Holmes E, Thornicroft G. (2013). Experiences of discrimination among people using mental health services in England 2008-2011. British Journal of Psychiatry [Suppl] 2013 Apr;55:s58-63. doi: 10.1192/bjp.bp.112.112.912


Levels of discrimination against mental heath service users are high and there was evidence that public attitudes relating to mental health deteriorated up to the mid-2000s. A population level intervention, Time to Change, was developed to tackle stigma and discrimination. It was funded for four years, 2007-11, at a cost of around £21 million. It included social contact and social marketing elements (which were delivered from 2009-11), and was delivered by the major mental health charities. It had clear goals and outcomes (set out by Thornicroft and Corker 2013 in  their editorial):

  • -significantly increased public awareness of mental health (an estimated 30 million English adults would be reached), a 5% positive shift in public attitudes towards mental health problems and a 5% reduction in discrimination by 2012;
  • -100 000 people with mental health problems to have increased knowledge, confidence and assertiveness to challenge discrimination by 2012;
  • -provision, through physical activity, of greater opportunities for 274 500 people with a range of mental health problems to come together, both to break down discrimination and to improve well-being, by 2012.

The paper under discussion is one of several that have come out of the official evaluation project led by the Institute of Psychiatry (Kings College London). They were published in a special supplement of the British Journal of Psychiatry in April 2013. The two editorials in the (fully open access) issue provide a good overview of the issues; of the Time to Change programme, and the overall evaluation results.  Some positive outcomes were achieved, although they fell short of the targets.

Other papers in the issue report on changes in attitudes of the general public, newspapers, and medical students, to people with mental health problems; on the impact of specific aspects of the programme (social marketing; social contact events); and provide an economic evaluation of the the campaign.

The experiences study

This survey study was designed to capture any changes in discrimination experienced by mental health service users between the period before TTC was implemented, up to 2011.
A telephone questionnaire was administered to people identified as mental health service users across different mental health trusts in England, in 2008, ’09, ’10 and ’11. The questions covered different areas of life, for example, family and friends, work and benefits. The questionnaire used was the ‘Discrimination and Stigma Scale ‘ (DISC), which was developed by an international team (some details here).

The authors report a small but significant overall increase in the proportion of the participants who had no experiences of discrimination in 2011 versus 2008. In all years, the great majority of respondents reported at least one experience of discrimination. Discrimination in four of the 21 domains covered in the questionnaire increased slightly over the period (safety, benefits, marriage and transport).

Questions for discussion
1. Does the study address a clearly focused question/issue? Is the study design appropriate to address this?
2. Were the methods of selecting and recruiting to the study adequately described; were they appropriate?
3. Was the sample adequate & representative of the population (mental health service users in England)?
4. Is the survey tool (DISC) likely to measure appropriately; is it a valid tool?
5. Results: are these presented adequately so that the reader can assess their validity & reliability? Are they adequately explained (any confounders)?
6. What implications are there for policy and practice?

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#PHTwitJC 24: Mental health- Time to Change evaluation

Time to Change logo

Next journal club chat will take place on Monday 22nd April, 8-9.00 pm (UK time)

Our topic is public health interventions relating to mental health, specifically, the impact of the Time to Change campaign in the UK, which started in 2009. This campaign was intended to ‘start a conversation’ about mental health in order to tackle stigma and discrimination, and a range of different interventions took place under the Time to Change banner.

s55.coverThis month saw the publication of a special issue of the British Journal of Psychiatry, containing several papers evaluating different aspects of Time to Change. Most of the papers in our poll are from this journal issue and all come from the same evaluation programme.

As usual with Public Health Twitter Journal Club chats, we suggest a selection of papers on the theme, and will focus on the article that receives the most votes. The poll will close on Thursday 18th, we will announce the ‘winner’ shortly afterwards. An introduction and some questions around which we’ll base Monday’s discussion, will be published on the blog a couple of days before the 22nd.

All of the papers in the poll are Open Access.

Full citations and links to the papers

Corker, Elizabeth et al (2013). Experiences of discrimination among people using mental health services in England 2008-2011.  The British Journal of Psychiatry 202: s58-s63 doi: 10.1192/bjp.bp.112.112912.

Evans-Lacko, Sara et al (2012) Mass social contact interventions and their effect on mental health related stigma and intended discrimination BMC Public Health 2012, 12:489 doi:10.1186/1471-2458-12-489 

Evans-Lacko, Sara, Claire Henderson and Graham Thornicroft (2013). Public knowledge, attitudes and behaviour regarding people with mental illness in England 2009-2012. The British Journal of Psychiatry (2013) 202: s51-s57 doi: 10.1192/bjp.bp.112.112979

Evans-Lacko,  Sara et al (2013) Economic evaluation of the anti-stigma social marketing campaign in England 2009-2011.  The British Journal of Psychiatry 202:s95-s101; doi:10.1192/bjp.bp.112.113746

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