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1.  Smoking in Movies and Adolescent Smoking Initiation 
Background
Longitudinal studies from the U.S. suggest a causal relationship between exposure to images of smoking in movies and adolescent smoking onset.
Purpose
This study investigates whether adolescent smoking onset is predicted by the amount of exposure to smoking in movies across six European countries with various cultural and regulatory approaches to tobacco.
Methods
Longitudinal survey of 9987 adolescent never-smokers recruited in the years 2009–2010 (mean age 13.2 years) in 112 state-funded schools from Germany, Iceland, Italy, The Netherlands, Poland, and the United Kingdom (UK), and followed-up in 2011. Exposure to movie smoking was estimated from 250 top-grossing movies in each country. Multilevel mixed-effects Poisson regressions were performed in 2012 to assess the relationship between exposure at baseline and smoking status at follow-up.
Results
During the observation period (M=12 months), 17% of the sample initiated smoking. The estimated mean exposure to on-screen tobacco was 1560 occurrences. Overall, and after controlling for age; gender; family affluence; school performance; TVscreen time; personality characteristics; and smoking status of peers, parents, and siblings, exposure to each additional 1000 tobacco occurrences increased the adjusted relative risk for smoking onset by 13% (95% CI=8%, 17%, p<0.001). The crude relationship between movie smoking exposure and smoking initiation was significant in all countries; after covariate adjustment, the relationship remained significant in Germany, Iceland, The Netherlands, Poland, and UK.
Conclusions
Seeing smoking in movies is a predictor of smoking onset in various cultural contexts. The results confirm that limiting young people’s exposure to movie smoking might be an effective way to decrease adolescent smoking onset.
doi:10.1016/j.amepre.2012.11.037
PMCID: PMC3616269  PMID: 23498098
2.  Are sexual media exposure, parental restrictions on media use and co-viewing TV and DVDs with parents and friends associated with teenagers' early sexual behaviour?☆ 
Journal of Adolescence  2013;36(6):1121-1133.
Sexual content in teenagers' media diets is known to predict early sexual behaviour. Research on sexual content has not allowed for the social context of media use, which may affect selection and processing of content. This study investigated whether sexual media content and/or contextual factors (co-viewing, parental media restrictions) were associated with early sexual behaviour using 2251 14–15 year-olds from Scotland, UK. A third (n = 733) reported sexual intercourse. In multivariable analysis the likelihood of intercourse was lower with parental restriction of sexual media and same-sex peer co-viewing; but higher with mixed-sex peer co-viewing. Parental co-viewing, other parental restrictions on media and sexual film content exposure were not associated with intercourse. Findings suggest the context of media use may influence early sexual behaviour. Specific parental restrictions on sexual media may offer more protection against early sex than other restrictions or parental co-viewing. Further research is required to establish causal mechanisms.
doi:10.1016/j.adolescence.2013.08.019
PMCID: PMC3847268  PMID: 24215959
Adolescent; Media; Sexual behaviour; Co-viewing
3.  Weight management for overweight and obese men delivered through professional football clubs: a pilot randomized trial 
Background
The prevalence of male obesity is increasing, but men are less likely than women to attend existing weight management programmes. We have taken a novel approach to reducing perceived barriers to weight loss for men by using professional football (soccer) clubs to encourage participation in a weight management group programme, gender-sensitised in content and style of delivery. Football Fans in Training (FFIT) provides 12 weeks of weight loss, physical activity and healthy eating advice at top professional football clubs in Scotland. This pilot randomized trial explored the feasibility of using these clubs as a setting for a randomized controlled trial of 12 month weight loss following men’s participation in FFIT.
Methods
A two-arm pilot trial at two Scottish Premier League football clubs (one large, one smaller), with 103 men (aged 35–65, body mass index (BMI) ≥27 kg/m2) individually randomized to the intervention (n=51, received the pilot programme (p-FFIT) immediately) and waitlist comparison (n=52, received p-FFIT after four months) groups. Feasibility of recruitment, randomization, data collection and retention were assessed. Objective physical measurements (weight, waist circumference, blood pressure, body composition) and questionnaires (self-reported physical activity, diet, alcohol consumption, psychological outcomes) were obtained from both groups by fieldworkers trained to standard protocols at baseline and 12 weeks, and from the intervention group at 6 and 12 months. Qualitative methods elicited men’s experiences of participation in the pilot trial.
Results
Following a short recruitment period, the recruitment target was achieved at the large, but not smaller, club. Participants’ mean age was 47.1±8.4 years; mean BMI 34.5±5.0 kg/m2. Retention through the trial was good (>80% at 12 weeks and 6 months; >75% at 12 months), and 76% attended at least 80% of available programme delivery sessions. At 12 weeks, the intervention group lost significantly more weight than the comparison group (4.6% c.f. -0.6%, p<.001) and many maintained this to 12 months (intervention group baseline-12 month weight loss: 3.5%, p<.001). There were also improvements in self-reported physical activity and diet, many sustained long term.
Conclusions
The results demonstrated the feasibility of trial procedures and the potential of FFIT to engage men in sustained weight loss and positive lifestyle change. They supported the conduct of a fully-powered randomized controlled trial.
doi:10.1186/1479-5868-10-121
PMCID: PMC3945776  PMID: 24171842
Overweight; Obesity; Physical activity; Diet; Behaviour change; Men; Gender; Masculinities; Intervention; Sports club
4.  The Role of Health Behaviours Across the Life Course in the Socioeconomic Patterning of All-Cause Mortality: The West of Scotland Twenty-07 Prospective Cohort Study 
Annals of Behavioral Medicine  2013;47:148-157.
Background
Socioeconomic differentials in mortality are increasing in many industrialised countries.
Purpose
This study aims to examine the role of behaviours (smoking, alcohol, exercise, and diet) in explaining socioeconomic differentials in mortality and whether this varies over the life course, between cohorts and by gender.
Methods
Analysis of two representative population cohorts of men and women, born in the 1950s and 1930s, were performed. Health behaviours were assessed on five occasions over 20 years.
Results
Health behaviours explained a substantial part of the socioeconomic differentials in mortality. Cumulative behaviours and those that were more strongly associated with socioeconomic status had the greatest impact. For example, in the 1950s cohort, the age-sex adjusted hazard ratio comparing respondents with manual versus non-manual occupational status was 1.80 (1.25, 2.58); adjustment for cumulative smoking over 20 years attenuated the association by 49 %, diet by 43 %, drinking by 13 % and inactivity by only 1%.
Conclusions
Health behaviours have an important role in explaining socioeconomic differentials in mortality.
doi:10.1007/s12160-013-9539-x
PMCID: PMC3964290  PMID: 24072618
Mortality; Socioeconomic status; Health behaviours; Cohort
5.  High youth access to movies that contain smoking in Europe compared with the USA 
Tobacco control  2011;22(4):241-244.
Background
Based on evidence that exposure to smoking in movies is associated with adolescent smoking, the WHO has called on countries to assign a rating that restricts youth access to such movies.
Objective
To evaluate youth access to movies that portray smoking in European countries and compare with that in the USA.
Methods
The authors identified the most commercially successful movies screened in six European countries (Germany, Iceland, Italy, the Netherlands, Poland and UK) and the USA between 2004 and 2009. The authors coded the 464 movies that were screened in both Europe and the USA according to whether or not they portrayed smoking.
Results
87% of the movies were ‘youth’ rated in Europe (ratings board classification as suitable for those younger than 16 years) compared to only 67% in the USA (suitable for those younger than 17 years). Smoking was portrayed in 319 (69%) movies. 85% of the movies that portrayed smoking were ‘youth’ rated in Europe compared with only 59% in the USA (p<0.001).
Conclusions
Tobacco imagery is still common in popular films shown in European countries and the USA. None of the seven countries examined followed the WHO recommendations on restricting youth access to movies that portray smoking. Compared to the USA, European youths have access to substantially more movies in general, and this gives them access to more movies that portray smoking in particular.
doi:10.1136/tobaccocontrol-2011-050050
PMCID: PMC3779888  PMID: 22184208
6.  Do men consult less than women? An analysis of routinely collected UK general practice data 
BMJ Open  2013;3(8):e003320.
Objective
To examine whether gender differences in primary care consultation rates (1) vary by age and deprivation status and (2) diminish when consultation for reproductive reasons or common underlying morbidities are accounted for.
Design
Cross-sectional study of a cohort of patients registered with general practice.
Setting
UK primary care.
Subjects
Patients (1 869 149 men and 1 916 898 women) registered with 446 eligible practices in 2010.
Primary outcome measures
Primary care consultation rate.
Results
This study analyses routinely collected primary care consultation data. The crude consultation rate was 32% lower in men than women. The magnitude of gender difference varied across the life course, and there was no ‘excess’ female consulting in early and later life. The greatest gender gap in primary care consultations was seen among those aged between 16 and 60 years. Gender differences in consulting were higher in people from more deprived areas than among those from more affluent areas. Accounting for reproductive-related consultations diminished but did not eradicate the gender gap. However, consultation rates in men and women who had comparable underlying morbidities (as assessed by receipt of medication) were similar; men in receipt of antidepressant medication were only 8% less likely to consult than women in receipt of antidepressant medication (relative risk (RR) 0.916, 95% CI 0.913 to 0.918), and men in receipt of medication to treat cardiovascular disease were just 5% less likely to consult (RR=0.950, 95% CI 0.948 to 0.952) than women receiving similar medication. These small gender differences diminished further, particularly for depression (RR=0.950, 95% CI 0.947 to 0.953), after also taking account of reproductive consultations.
Conclusions
Overall gender differences in consulting are most marked between the ages of 16 and 60 years; these differences are only partially accounted for by consultations for reproductive reasons. Differences in consultation rates between men and women were largely eradicated when comparing men and women in receipt of medication for similar underlying morbidities.
doi:10.1136/bmjopen-2013-003320
PMCID: PMC3753483  PMID: 23959757
Primary Care; Health Services Administration & Management; Epidemiology; Social Medicine
7.  Smoking in movies and adolescent smoking: cross-cultural study in six European countries 
Thorax  2011;66(10):875-883.
Aim
To investigate whether the association between exposure to smoking in movies and smoking among youth is independent of cultural context.
Method
Cross-sectional survey of 16 551 pupils recruited in Germany, Iceland, Italy, the Netherlands, Poland and Scotland with a mean age of 13.4 years (SD=1.18) and an equal gender distribution. School-based surveys were conducted between November 2009 and June 2010. Using previously validated methods, exposure to movie smoking was estimated from the 250 top-grossing movies of each country (years 2004–2009) and related to ever smoking.
Results
Overall, 29% of the sample had tried smoking. The sample quartile (Q) of movie smoking exposure was significantly associated with the prevalence of ever smoking: 14% of adolescents in Q1 had tried smoking, 21% in Q2, 29% in Q3 and 36% in Q4. After controlling for age, gender, family affluence, school performance, television screen time, number of movies seen, sensation seeking and rebelliousness and smoking within the social environment (peers, parents and siblings), the adjusted ORs for having tried smoking in the entire sample were 1.3 (95% CI 1.1 to 1.5) for adolescents in Q2, 1.6 (95% CI 1.4 to 1.9) for Q3 and 1.7 (95% CI 1.4 to 2.0) for Q4 compared with Q1. The adjusted relationship between ever smoking and higher movie smoking exposure levels was significant in all countries with a non-linear association in Italy and Poland.
Conclusions
The link between smoking in movies and adolescent smoking is robust and transcends different cultural contexts. Limiting young people's exposure to movie smoking could have important public health implications.
doi:10.1136/thoraxjnl-2011-200489
PMCID: PMC3719161  PMID: 21873322
8.  Exposure to smoking in films and own smoking among Scottish adolescents: a cross-sectional study 
Thorax  2011;66(10):866-874.
Background
Evidence of high exposure of UK youth to images of smoking in films has led to calls for an 18 rating for films with smoking to reduce smoking in youth. However, the only study to date in the UK to test for an association showed no relation between film-smoking exposure and smoking among young adults.
Objective
To assess whether there is an association between exposure to film images of smoking and own smoking among UK adolescents and whether repeated viewings of films has an impact.
Design
Cross-sectional study.
Participants
1999 pupils aged 15–16 years from 13 Scottish schools.
Outcome
Smoked tobacco in the past year.
Exposure measure
Film-smoking exposure was assessed using the Beach method; account for repeated viewings of films was then used to modify estimated exposure. Covariates included: media usage, parental restriction on and context of TV/film viewing, family connectedness, parental monitoring and friends' smoking.
Results
Most (71%) students had not smoked in the past year. About half reported no parental restrictions on TV/film viewing. Many reported repeated viewings of films; accounting for this more than doubled exposure estimates and strengthened the association with smoking. Adolescents with high exposure to film smoking were more likely to have smoked than those with low exposure (adjusted odds ratio (AOR) 2.08, 95% CI 1.22 to 3.55). Additionally, adolescents who reported parental rules about TV/film watching were less likely to smoke (AOR 0.37 (0.27 to 0.52)) than those who did not. Adolescents who mainly watched films with friends had higher exposure to film smoking and were more likely to smoke (AOR 2.19 (1.10 to 4.38)).
Conclusions
Exposure to film smoking is associated with smoking among Scottish adolescents. These data lend support to calls for an 18 rating for films with images of smoking.
doi:10.1136/thoraxjnl-2011-200095
PMCID: PMC3719166  PMID: 21764893
9.  Alcohol Consumption in Movies and Adolescent Binge Drinking in 6 European Countries 
Pediatrics  2012;129(4):709-720.
OBJECTIVE:
The goal of this study was to investigate whether the association between exposure to images of alcohol use in movies and binge drinking among adolescents is independent of cultural context.
METHODS:
A cross-sectional survey study in 6 European countries (Germany, Iceland, Italy, Netherlands, Poland, and Scotland) was conducted. A total of 16 551 pupils from 114 public schools with a mean (± SD) age of 13.4 (± 1.18) years participated. By using previously validated methods, exposure to alcohol use in movies was estimated from the 250 top-grossing movies of each country (years 2004−2009). Lifetime binge drinking was the main outcome measure.
RESULTS:
Overall, 27% of the sample had consumed >5 drinks on at least 1 occasion in their life. After controlling for age, gender, family affluence, school performance, television screen time, sensation seeking and rebelliousness, and frequency of drinking of peers, parents, and siblings, the adjusted β-coefficient for lifetime binge drinking in the entire sample was 0.12 (95% confidence interval: 0.10−0.14; P < .001). The crude relationship between movie alcohol use exposure and lifetime binge drinking was significant in all countries; after covariate adjustment, the relationship was still significant in 5 of 6 countries. A sensitivity analysis revealed that the association is content specific, as there was no significant association between lifetime binge drinking and exposure to smoking in movies.
CONCLUSIONS:
The link between alcohol use in movies and adolescent binge drinking was robust and seems relatively unaffected by cultural contexts.
doi:10.1542/peds.2011-2809
PMCID: PMC3313641  PMID: 22392174
alcohol; Europe; exposure; media; youth
10.  Football Fans in Training: the development and optimization of an intervention delivered through professional sports clubs to help men lose weight, become more active and adopt healthier eating habits 
BMC Public Health  2013;13:232.
Background
The prevalence of obesity in men is rising, but they are less likely than women to engage in existing weight management programmes. The potential of professional sports club settings to engage men in health promotion activities is being increasingly recognised. This paper describes the development and optimization of the Football Fans in Training (FFIT) programme, which aims to help overweight men (many of them football supporters) lose weight through becoming more active and adopting healthier eating habits.
Methods
The MRC Framework for the design and evaluation of complex interventions was used to guide programme development in two phases. In Phase 1, a multidisciplinary working group developed the pilot programme (p-FFIT) and used a scoping review to summarize previous research and identify the target population. Phase 2 involved a process evaluation of p-FFIT in 11 Scottish Premier League (SPL) clubs. Participant and coach feedback, focus group discussions and interviews explored the utility/acceptability of programme components and suggestions for changes. Programme session observations identified examples of good practice and problems/issues with delivery. Together, these findings informed redevelopment of the optimized programme (FFIT), whose components were mapped onto specific behaviour change techniques using an evidence-based taxonomy.
Results
p-FFIT comprised 12, weekly, gender-sensitised, group-based weight management classroom and ‘pitch-side’ physical activity sessions. These in-stadia sessions were complemented by an incremental, pedometer-based walking programme. p-FFIT was targeted at men aged 35-65 years with body mass index ≥ 27 kg/m2. Phase 2 demonstrated that participants in p-FFIT were enthusiastic about both the classroom and physical activity components, and valued the camaraderie and peer-support offered by the programme. Coaches appreciated the simplicity of the key healthy eating and physical activity messages. Suggestions for improvements that were incorporated into the optimized FFIT programme included: more varied in-stadia physical activity with football-related components; post-programme weight management support (emails and a reunion session); and additional training for coaches in SMART goal setting and the pedometer-based walking programme.
Conclusions
The Football Fans in Training programme is highly acceptable to participants and SPL coaches, and is appropriate for evaluation in a randomised controlled trial.
doi:10.1186/1471-2458-13-232
PMCID: PMC3621078  PMID: 23496915
11.  How robust is the evidence of an emerging or increasing female excess in physical morbidity between childhood and adolescence? Results of a systematic literature review and meta-analyses 
Social Science & Medicine (1982)  2013;78(C):96-112.
For asthma and psychological morbidity, it is well established that higher prevalence among males in childhood is replaced by higher prevalence among females by adolescence. This review investigates whether there is evidence for a similar emerging female ‘excess’ in relation to a broad range of physical morbidity measures. Establishing whether this pattern is generalised or health outcome-specific will further understandings of the aetiology of gender differences in health. Databases (Medline; Embase; CINAHL; PsycINFO; ERIC) were searched for English language studies (published 1992–2010) presenting physical morbidity prevalence data for males and females, for at least two age-bands within the age-range 4–17 years. A three-stage screening process (initial sifting; detailed inspection; extraction of full papers), was followed by study quality appraisals. Of 11 245 identified studies, 41 met the inclusion criteria. Most (n = 31) presented self-report survey data (five longitudinal, 26 cross-sectional); 10 presented routinely collected data (GP/hospital statistics). Extracted data, supplemented by additional data obtained from authors of the included studies, were used to calculate odds ratios of a female excess, or female:male incident rate ratios as appropriate. To test whether these changed with age, the values were logged and regressed on age in random effects meta-regressions. These showed strongest evidence of an emerging/increasing female excess for self-reported measures of headache, abdominal pain, tiredness, migraine and self-assessed health. Type 1 diabetes and epilepsy, based on routinely collected data, did not show a significant emerging/increasing female excess. For most physical morbidity measures reviewed, the evidence broadly points towards an emerging/increasing female excess during the transition to adolescence, although results varied by morbidity measure and study design, and suggest that this may occur at a younger age than previously thought.
Highlights
► Review of international evidence of gender-by-age differences in child and adolescent physical morbidity. ► Meta-regressions show an emerging/increasing female excess for several measures. ► An emerging/increasing male excess was seen for type 1 diabetes only. ► Findings suggest female excess physical morbidity emerges in mid-late childhood. ► Longitudinal studies commencing in childhood are needed to understand gender patterning of health.
doi:10.1016/j.socscimed.2012.11.039
PMCID: PMC3566587  PMID: 23273876
Physical morbidity; Child; Adolescent; Gender; Review; Meta-analyses; Headache; Diabetes
12.  Positive associations between consumerism and tobacco and alcohol use in early adolescence: cross-sectional study 
BMJ Open  2012;2(5):e001446.
Background
There is concern about the negative impact of modern consumer culture on young people's mental health, but very few studies have investigated associations with substance use. In those which have, positive associations have been attributed to attempts to satisfy the unmet needs of more materialistic individuals.
Objectives
This study examines associations between different dimensions of consumerism and tobacco and alcohol use among Scottish early adolescents.
Design
Cross-sectional study.
Setting and participants
2937 (92% of those eligible) secondary school pupils (ages 12–14) completed questionnaires in examination conditions. Analyses were restricted to those with complete data on all relevant variables (N=2736 smoking; N=2737 drinking).
Measures
Dependent variables comprised ever smoking and current drinking. Measures of consumerism comprised number of ‘premium’ (range 0–7) and ‘standard’ (range 0–5) material possessions and three Consumer Involvement subscales, ‘dissatisfaction’, ‘consumer orientation’ and ‘brand awareness’ (each range 3–12). Analyses also included school-year group and family affluence.
Results
Ever smoking and current drinking were both more prevalent among adolescents with more ‘premium’ and ‘standard’ material possessions, greater consumer ‘dissatisfaction’ and ‘brand awareness’ (mutually adjusted analyses including school-year group and family affluence). The strongest relationships occurred for ‘brand awareness’: for each unit increase in ‘brand awareness’ the ORs (95% CI) of ever smoking were 1.17 (1.08 to 1.26) and 1.23 (1.14 to 1.33) in males and females, respectively; and those for drinking were 1.15 (1.08 to 1.23) and 1.21 (1.13 to 1.30). ‘Brand awareness’ had an equal or stronger relationship with both smoking and drinking than did family affluence.
Conclusions
These results suggest aassociations between consumerism and both smoking and drinking might arise because adolescent identities incorporate both consumerism and substance use, or be the result of promotion (indirectly in the case of tobacco) linking consumerist or aspirational lifestyles with these behaviours.
doi:10.1136/bmjopen-2012-001446
PMCID: PMC3467633  PMID: 23012331
Social Medicine; Public Health; Epidemiology
13.  Comparing the effectiveness of using generic and specific search terms in electronic databases to identify health outcomes for a systematic review: a prospective comparative study of literature search methods 
BMJ Open  2012;2(3):e001043.
Objective
To compare the effectiveness of systematic review literature searches that use either generic or specific terms for health outcomes.
Design
Prospective comparative study of two electronic literature search strategies. The ‘generic’ search included general terms for health such as ‘adolescent health’, ‘health status’, ‘morbidity’, etc. The ‘specific’ search focused on terms for a range of specific illnesses, such as ‘headache’, ‘epilepsy’, ‘diabetes mellitus’, etc.
Data sources
The authors searched Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO and the Education Resources Information Center for studies published in English between 1992 and April 2010.
Main outcome measures
Number and proportion of studies included in the systematic review that were identified from each search.
Results
The two searches tended to identify different studies. Of 41 studies included in the final review, only three (7%) were identified by both search strategies, 21 (51%) were identified by the generic search only and 17 (41%) were identified by the specific search only. 5 of the 41 studies were also identified through manual searching methods. Studies identified by the two ELS differed in terms of reported health outcomes, while each ELS uniquely identified some of the review's higher quality studies.
Conclusions
Electronic literature searches (ELS) are a vital stage in conducting systematic reviews and therefore have an important role in attempts to inform and improve policy and practice with the best available evidence. While the use of both generic and specific health terms is conventional for many reviewers and information scientists, there are also reviews that rely solely on either generic or specific terms. Based on the findings, reliance on only the generic or specific approach could increase the risk of systematic reviews missing important evidence and, consequently, misinforming decision makers. However, future research should test the generalisability of these findings.
Article summary
Article focus
Providing evidence-based guidance to improve electronic literature searches (ELS): an often overlooked but vital stage in our efforts to inform policy and practice with the best available evidence.
During systematic review literature search we conducted two ELS and compared the results: one ELS included search terms for a range of specific health conditions, while the other included only generic terms for health and illness.
Key messages
Future systematic reviews that involve multiple health outcomes should include both generic and specific health terms in their literature search.
Based on our findings, previous reviews that have only used one of these approaches may have failed to identify relevant evidence and this in turn could have affected the reviewers' conclusions.
Systematic reviews that miss important evidence risk causing harm by misinforming practitioners and other decision makers.
Strengths and limitations of this study
The relatively novel application of a prospective comparative study design to the issue of electronic literature searching is a key strength.
Although the searches identified over 10 000 initial records, they could have been made more sensitive through greater use of techniques such as truncation, synonyms and by searching additional databases.
The study is based on searches conducted for a specific review, so the generalisablity of our findings should be tested in the context of other reviews and different types of literature search, including more sensitive searches.
doi:10.1136/bmjopen-2012-001043
PMCID: PMC3383975  PMID: 22734117
14.  School nurses' experiences of delivering the UK HPV vaccination programme in its first year 
BMC Infectious Diseases  2011;11:226.
Background
In the United Kingdom (UK) in September 2008, school nurses began delivering the HPV immunisation programme for girls aged 12 and 13 years old. This study offers insights from school nurses' perspectives and experiences of delivering this new vaccination programme.
Methods
Thirty in-depth telephone interviews were conducted with school nurses working across the UK between September 2008 and May 2009. This time period covers the first year of the HPV vaccination programme in schools. School nurses were recruited via GP practices, the internet and posters targeted at school nurse practitioners.
Results
All the school nurses spoke of readying themselves for a deluge of phone calls from concerned parents, but found that in fact few parents telephoned to ask for more information or express their concerns about the HPV vaccine. Several school nurses mentioned a lack of planning by policy makers and stated that at its introduction they felt ill prepared. The impact on school nurses' workload was spoken about at length by all the school nurses. They believed that the programme had vastly increased their workload leading them to cut back on their core activities and the time they could dedicate to offering support to vulnerable pupils.
Conclusion
Overall the first year of the implementation of the HPV vaccination programme in the UK has exceeded school nurses' expectations and some of its success may be attributed to the school nurses' commitment to the programme. It is also the case that other factors, including positive newsprint media reporting that accompanied the introduction of the HPV vaccination programme may have played a role. Nevertheless, school nurses also believed that the programme had vastly increased their workload leading them to cut back on their core activities and as such they could no longer dedicate time to offer support to vulnerable pupils. This unintentional aspect of the programme may be worthy of further exploration.
doi:10.1186/1471-2334-11-226
PMCID: PMC3176210  PMID: 21864404
HPV vaccination; cervical; cancer; school nurses
15.  Words matter: a qualitative investigation of which weight status terms are acceptable and motivate weight loss when used by health professionals 
BMC Public Health  2011;11:513.
Background
Health professionals have an important role to play in the management of obesity, but may be unsure how to raise weight issues with patients. The societal stigma associated with excess weight means that weight status terms may be misunderstood, cause offence and risk upsetting patient-professional relationships. This study investigated the views of people who were overweight or obese on the acceptability of weight status terms and their potential to motivate weight loss when used by health professionals.
Methods
A qualitative study comprising 34 semi-structured interviews with men and women in their mid-to-late 30s and 50s who were overweight or obese and had recently been informed of their weight status. Thematic framework analysis was conducted to allow the systematic comparison of views by age, gender and apparent motivation to lose weight.
Results
Although many people favoured 'Overweight' to describe their weight status, there were doubts about its effectiveness to motivate weight loss. Terms including 'BMI' ('Body Mass Index') or referring to the unhealthy nature of their weight were generally considered acceptable and motivational, although a number of men questioned the validity of BMI as an indicator of excess weight. Participants, particularly women, felt that health professionals should avoid using 'Fat'. Whilst response to 'Obese' was largely negative, people recognised that it could be appropriate in a health consultation. Some younger people, particularly those who appeared motivated to lose weight, felt 'Obese' could encourage weight loss, but it was also clear the term could provoke negative emotions if used insensitively.
Conclusions
Although most people who are overweight or obese accept that it is appropriate for health professionals to discuss weight issues with patients, there is great variation in response to the terms commonly used to describe excess weight. There is no one-size-fits-all approach to discussing weight status: some men and younger people may appreciate a direct approach, whilst others need to be treated more sensitively. It is therefore important that health professionals use their knowledge and understanding to select the terms that are most likely to be acceptable, but at the same time have most potential to motivate each individual patient.
doi:10.1186/1471-2458-11-513
PMCID: PMC3142235  PMID: 21714892
16.  Do women consult more than men? A review of gender and consultation for back pain and headache 
Objectives
Because women consult their general practitioners more frequently on average than men, it is commonly assumed that they consult more for all symptoms and conditions. This assumption is reinforced by qualitative studies reporting a widespread reluctance to consult by men. However, few studies directly compare consultation in men and women experiencing similar symptoms or conditions.
Methods
A systematic review of the evidence on gender and consultation for two common symptoms, back pain and headache. Extensive electronic searches identified 15 papers reporting the relationship between gender and help-seeking for back pain and 11 papers for headache. Two independent reviewers assessed articles for inclusion and extracted data from eligible studies.
Results
Few studies compared consultation patterns for these symptoms among men and women known to have experienced the symptom. The quality of the studies was variable. Overall, evidence for greater consultation by women with back pain was weak and inconsistent. Among those with back pain, the odds ratios for women seeking help, compared with men, ranged from 0.6 (95% confidence intervals 0.3, 1.2, adjusted only for age) to 2.17 (95% confidence intervals 1.35, 3.57, unadjusted), although none of the reported odds ratio, below 1.00 was statistically significant. The evidence for women being more likely to consult for headache was a little stronger. Five studies showed a statistically elevated odds ratio, and none suggested that men with headache symptoms were more likely to consult than women with headache symptoms. Limitations to the studies are discussed.
Conclusion
Given the strength of assumptions that women consult more readily for common symptoms, the evidence for greater consultation amongst women for two common symptoms, headache and back pain, was surprisingly weak and inconsistent, especially with respect to back pain.
doi:10.1258/jhsrp.2010.009131
PMCID: PMC3104816  PMID: 20819913
17.  Is there an association between seeing incidents of alcohol or drug use in films and young Scottish adults' own alcohol or drug use? A cross sectional study 
BMC Public Health  2011;11:259.
Background
As the promotion of alcohol and tobacco to young people through direct advertising has become increasingly restricted, there has been greater interest in whether images of certain behaviours in films are associated with uptake of those behaviours in young people. Associations have been reported between exposure to smoking images in films and smoking initiation, and between exposure to film alcohol images and initiation of alcohol consumption, in younger adolescents in the USA and Germany. To date no studies have reported on film images of recreational drug use and young people's own drug use.
Methods
Cross sectional multivariable logistic regression analysis of data collected at age 19 (2002-4) from a cohort of young people (502 boys, 500 girls) previously surveyed at ages 11 (in 1994-5), 13 and 15 in schools in the West of Scotland. Outcome measures at age 19 were: exceeding the 'sensible drinking' guidelines ('heavy drinkers') and binge drinking (based on alcohol consumption reported in last week), and ever use of cannabis and of 'hard' drugs. The principle predictor variables were an estimate of exposure to images of alcohol, and of drug use, in films, controlling for factors related to the uptake of substance use in young people.
Results
A third of these young adults (33%) were classed as 'heavy drinkers' and half (47%) as 'binge drinkers' on the basis of their previous week's consumption. Over half (56%) reported ever use of cannabis and 13% ever use of one or more of the 'hard' drugs listed. There were linear trends in the percentage of heavy drinkers (p = .018) and binge drinkers (p = 0.012) by film alcohol exposure quartiles, and for ever use of cannabis by film drug exposure (p = .000), and for ever use of 'hard' drugs (p = .033). The odds ratios for heavy drinking (1.56, 95% CI 1.06-2.29 comparing highest with lowest quartile of film alcohol exposure) and binge drinking (1.59, 95% CI 1.10-2.30) were attenuated by adjustment for gender, social class, family background (parental structure, parental care and parental control), attitudes to risk-taking and rule-breaking, and qualifications (OR heavy drinking 1.42, 95% CI 0.95-2.13 and binge drinking 1.49, 95% CI 1.01-2.19), and further so when adjusting for friends' drinking status (when the odds ratios were no longer significant). A similar pattern was seen for ever use of cannabis and 'hard' drugs (unadjusted OR 1.80, 95% CI 1.24-2.62 and 1.57, 95% CI 0.91-2.69 respectively, 'fully' adjusted OR 1.41 (0.90-2.22 and 1.28 (0.66-2.47) respectively).
Conclusions
Despite some limitations, which are discussed, these cross-sectional results add to a body of work which suggests that it is important to design good longitudinal studies which can determine whether exposure to images of potentially health-damaging behaviours lead to uptake of these behaviours during adolescence and early adulthood, and to examine factors that might mediate this relationship.
doi:10.1186/1471-2458-11-259
PMCID: PMC3123204  PMID: 21513542
alcohol; drugs; films; movies; adolescents
18.  Response to written feedback of clinical data within a longitudinal study: a qualitative study exploring the ethical implications 
Background
There is a growing ethical imperative to feedback research results to participants but there remains a striking lack of empirical research on how people respond to individualised feedback. We sought to explore longitudinal study participants' response to receiving individual written feedback of weight-related and blood results, and to consider the balance of harms against benefits.
Methods
A qualitative study with face-to-face and telephone interviews conducted with 50 men and women who had participated in the fifth and most recent wave of the cohort study 'West of Scotland Twenty-07' and received a feedback letter containing body mass index (BMI), body fat percentage, cholesterol and glycated haemoglobin A1c (HbA1c) results.
Results
Expectations of, and response to, the feedback of their individual results varied. Whilst half of the participants were on the whole 'pleased' with their results or held neutral views, half reported negative responses such as 'shock' or 'concern', particularly in relation to the weight-related results. Participants who were overweight and obese used the most negative language about their results, with some being quite distressed and reporting feelings of powerlessness, low self-image and anxiety over future health. Nevertheless, some people reported having implemented lifestyle changes in direct response to the feedback, resulting in significant weight-loss and/or dietary improvements. Others reported being motivated to change their behaviour. Age and gender differences were apparent in these narratives of behaviour change.
Conclusions
The potential harm caused to some participants may be balanced against the benefit to others. More evaluation of the impact of the format, content and means of individualised feedback of research findings in non-trial studies is required given the growing ethical imperative to offer participants a choice of receiving their results, and the likelihood that a high percentage will choose to receive them.
doi:10.1186/1471-2288-11-10
PMCID: PMC3041784  PMID: 21272336
19.  Contribution of smoking-related and alcohol-related deaths to the gender gap in mortality: evidence from 30 European countries 
Tobacco Control  2011;20(2):166-168.
Background
Women now outlive men throughout the globe, a mortality advantage that is very established in developed European countries. Debate continues about the causes of the gender gap, although smoking is known to have been a major contributor to the difference in the past.
Objectives
To compare the magnitude of the gender gap in all-cause mortality in 30 European countries and assess the contribution of smoking-related and alcohol-related deaths.
Methods
Data on all-cause mortality, smoking-related mortality and alcohol-related mortality for 30 European countries were extracted from the World Health Organization Health for All database for the year closest to 2005. Rates were standardised by the direct method using the European population standard and were for all age groups. The proportion of the gender gap in all-cause mortality attributable to smoking-related and alcohol-related deaths was then calculated.
Results
There was considerable variation in the magnitude of the male ‘excess’ of all-cause mortality across Europe, ranging from 188 per 100 000 per year in Iceland to 942 per 100 000 per year in Ukraine. Smoking-related deaths accounted for around 40% to 60% of the gender gap, while alcohol-related mortality typically accounted for 20% to 30% of the gender gap in Eastern Europe and 10% to 20% elsewhere in Europe.
Conclusions
Smoking continues to be the most important cause of gender differences in mortality across Europe, but its importance as an explanation for this difference is often overshadowed by presumptions about other explanations. Changes in smoking patterns by gender suggest that the gender gap in mortality will diminish in the coming decades.
doi:10.1136/tc.2010.037929
PMCID: PMC3045524  PMID: 21228431
Smoking-related mortality; alcohol-related mortality; gender difference; smoking caused disease
20.  UK newspapers' representations of the 2009–10 outbreak of swine flu: one health scare not over-hyped by the media? 
Background
A/H1N1, more commonly referred to as swine flu, emerged in Mexico in spring 2009. It rapidly spread across the world and was classed as a global pandemic on 11 June 2009.
Objective
To analyse UK newsprint coverage of the swine flu pandemic.
Methods
Content analysis of 2374 newsprint articles published in eight UK national newspapers between 1 March 2009 and 28 February 2010.
Results
Newsprint coverage of the swine flu epidemic was immense. The threat from swine flu was portrayed as greatest in the spring and summer of 2009 when scientific uncertainties about the impact on the UK and global population were at their height and when swine flu cases in the UK first peaked. Thereafter the number of news articles waned, failing to mirror the October peak in flu cases as the virus failed to be as virulent as first feared. Content analysis found little evidence of the media ‘over-hyping’ the swine flu pandemic.
Conclusions
The news media's role as a disseminator of scientific information is particularly important in areas of risk perception. Despite a succession of health scares in recent years in which the media has been accused of exaggerating the risks and contributing to public misunderstandings of the issues, this analysis suggests that the UK newsprint reporting of swine flu in the 2009–10 outbreak was largely measured. The news media's role as disseminators of factual health information on swine flu is to be welcomed, particularly in relation to their handling and responsible reporting on scientific uncertainty.
doi:10.1136/jech.2010.119875
PMCID: PMC3171979  PMID: 21131303
Swine flu; A/H1N1; newspapers; content analysis; public health gen sa
21.  The influence of socio-demographic characteristics on consultation for back pain—a review of the literature 
Family Practice  2010;28(2):163-171.
Background. There are several assumptions within clinical practice about who is more or less likely to consult a health care practitioner for particular symptoms, most commonly these focus around socio-demographic characteristics. We aimed to assess the evidence for the impact of socio-demographic characteristics on consultation for back pain.
Methods. We conducted a review of the literature, using systematic methods, on consultation for back pain. Using systematic searching techniques we identified peer-reviewed publications that focused on health care consultation in response to symptoms of back pain and which included data on both users and non-users of health care.
Results. We identified 23 studies. Definitions of help-seeking were inconsistent across studies. The majority of the 15 studies which considered the relationship between age and help-seeking for back pain did not find evidence of an association between these two factors. Seventeen studies considered whether socio-economic position was associated with help-seeking. The evidence largely supported the conclusion of no association (13 papers). Fifteen studies included gender as a variable in their analyses, and the majority (10 papers) presented the finding of no association.
Conclusions. The results from this review suggest that there is little evidence to support the common wisdom that socio-demographic characteristics impact on help-seeking in the context of back pain. As these assumptions relating to who is more or less likely to consult will ultimately affect patient care, it is important that they do not go unchallenged.
doi:10.1093/fampra/cmq085
PMCID: PMC3062780  PMID: 20974654
Consultation; pain; socio-demographic; systematic review
23.  Coverage of Jade Goody's cervical cancer in UK newspapers: a missed opportunity for health promotion? 
BMC Public Health  2010;10:368.
Background
It has been claimed that publicity surrounding popular celebrity Jade Goody's experience of cervical cancer will raise awareness about the disease. This study examines the content of newspaper articles covering her illness to consider whether 'mobilising information' which could encourage women to adopt risk-reducing and health promoting behaviours has been included.
Methods
Content analysis of 15 national newspapers published between August 2008 and April 2009
Findings
In the extensive coverage of Goody's illness (527 articles in the 7 months of study) few newspaper articles included information that might make women more aware of the signs and symptoms or risk factors for the disease, or discussed the role of the human papilloma virus (HPV) and the recently introduced HPV vaccination programme to reduce the future incidence of cervical cancer. For example, less than 5% of articles mentioned well-known risk-factors for cervical cancer and less than 8% gave any information about HPV. The 'human interest' aspects of Goody's illness (her treatment, the spread of her disease in later months, her wedding, and her preparations for her children's future) were more extensively covered.
Conclusions
Newspaper coverage of Goody's illness has tended not to include factual or educational information that could mobilise or inform women, or help them to recognise early symptoms. However, the focus on personal tragedy may encourage women to be receptive to HPV vaccination or screening if her story acts as a reminder that cervical cancer can be a devastating and fatal disease in the longer term.
doi:10.1186/1471-2458-10-368
PMCID: PMC2909165  PMID: 20576115
24.  MMR: marginalised, misrepresented and rejected? Autism: a focus group study 
Archives of Disease in Childhood  2007;92(4):322-327.
Objective
To explore how the measles, mumps, and rubella (MMR) vaccine controversy impacted on the lives of parents caring for children with autism.
Design
Qualitative focus group study.
Setting
United Kingdom.
Patients
A purposively selected sample of 38 parents took part in 10 focus group discussions between March 2003 and May 2005.
Results
Many parents felt that the MMR vaccine could be too potent for children who are susceptible to developing autism. Of the parents whose children received the MMR vaccine, many felt guilty that they may have caused or contributed to their child's autism. Some parents felt frustrated by health professionals' lack of understanding of the negative impact the MMR controversy has had on them. Some parents were anxious about subsequent MMR decision‐making for their children.
Conclusions
The controversy has had a negative impact on some parents of children with autism. This has implications for health professionals, who need to be particularly aware of the issues these parents face in future MMR decision‐making for their affected child and younger siblings. It is anticipated that these findings will raise awareness among health professionals of the difficulties faced by such parents. More generally, there is a need to promote a greater awareness of the important role health visitors can play in parental decision‐making and for research examining whether health professionals feel they receive sufficient training in communication skills. It is also essential that the latest scientific research findings are disseminated quickly to these parents and to those health professionals advising parents on matters of vaccine safety.
doi:10.1136/adc.2006.109686
PMCID: PMC2083659  PMID: 17376937
25.  Newsprint media representations of the introduction of the HPV vaccination programme for cervical cancer prevention in the UK (2005–2008) 
Social Science & Medicine (1982)  2010;70(6):942-950.
In September 2008, the human papillomavirus (HPV) immunisation programme was introduced in the UK for schoolgirls aged between 12 and 18 years of age. The vaccine shows high efficacy in preventing infection against HPV types 16 and 18 responsible for 70% of cervical cancer. However, to be most effective, the vaccine needs to be administered before exposure to the viruses and therefore, ideally, before young people become sexually active. The introduction of any new vaccine, and perhaps particularly one given to young teenage girls to prevent a sexually transmitted cancer-causing virus, has the potential to attract a great deal of media attention. This paper reports on content analysis of 344 articles published between January 2005 and December 2008 in 15 UK newspapers. It includes both manifest and latent analysis to examine newsprint media coverage of the introduction of the HPV vaccination programme and its role in HPV advocacy. We concluded that the newspapers were generally positive towards the new HPV vaccination and that over the 4 years period the newsworthiness of the HPV vaccination programme increased. In 2008 two events dominated coverage, firstly, the introduction of the HPV programme in September 2008 and secondly, in August 2008 the diagnosis on camera of cervical cancer given to Jade Goody, a 27 year old mother of two, who gained fame and notoriety in the UK through her participation in several reality television shows.
There are two conclusions from this study. Firstly, the positive media coverage surrounding the introduction of the HPV vaccination programme is to be welcomed as it is likely to contribute towards influencing public perceptions about the acceptability and need for HPV vaccination. Secondly, the focus on prevalence rates of HPV infection among women and on women's sexual behaviours, in relation to HPV vaccination ‘encouraging’ promiscuity, is an unhelpful aspect of media coverage.
doi:10.1016/j.socscimed.2009.11.027
PMCID: PMC2835855  PMID: 20064682
UK; Human papillomavirus (hpv); Vaccination; Mass media; Content analysis; Cervical cancer

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