Public Health Institute case studies

The Public Health Institute brings together 20 years of intelligence and evidence based research within the Image and Performance Enhancement Drug (IPED) field, this knowledge is enhanced by our collaborative partnerships at national and international levels. More specifically and nearer to home, we have developed strong collaborations with national organisations such as: Public Health England, Public Health Wales, NHS Scotland, drug service providers and IPED users throughout the country. IPEDs are a collective term used to describe drugs such as anabolic steroids (synthetic substances which mimic the actions of the male hormone, testosterone) and growth hormones. Traditionally these drugs have been used within elite sport, bodybuilding and power lifting to enhance body shape physique (including muscle growth and strength) and physical performance as well as predominately for aesthetic purposes. In recent times IPEDs have transcended the sporting arena to the general population in the UK.  For example, the latest Crime Survey for England and Wales (CSEW) 2015/16 estimates that 271,000 individuals aged 16-59 report ever using anabolic steroids and an estimate of 54,000 users report using in the last 12 months (the CSEW is generally accepted to be a considerable underestimation of anabolic steroid use).  

Since 2012, our national collaborations have led to annual nationwide surveys where we have recruited more than 1,500 IPED users. Survey participants were recruited from areas throughout England, Wales and Scotland within local communities such as gyms and service providers such as needle and syringe programmes. These data have been presented in international conferences, annual reports and academic papers where we have identified:

• The extent of IPED use within sub-group populations
• Behavioural use such as, route of administration, injecting practices, drug cycles and polydrug use and users motivations for use
• Emerging risks and health harms (including HIV and other Blood-borne Viruses [BBV])
• Harm reduction advice and guidance

There are a range of emerging health issues associated with the use of IPEDs.  Some of the most commonly reported adverse effects include; acne, accelerated balding, gynaecomastia, sexual-dysfunction, mood changes and psychological effects as well as more chronic conditions such as cardiac, metabolic, neurologic and musculoskeletal disorders. Possibly the most significant threat to this population lies in the risks associated with injecting practices, including both injuries and infections. Globally there is growing concern about the extent and public health consequences of IPED use, in particular infections such as HIV and hepatitis B and C. Although IPED users are reportedly at lower risk of injection-related infections compared with injecting psychoactive substance users, IPED users commonly report lower levels of condom use and increased sexual drive and are therefore at risk of both injection related and sexual transmission infections.

Data from our IPED surveys indicate that despite experiencing adverse effects individuals often chose to either wait for the symptoms to go away or self-medicate with natural remedies or other pharmaceutical substances. IPED users are reluctant to seek professional medical advice, treatment for adverse effects or testing for BBVs. Health and drug services must therefore respond to the specific needs of this group of drug users. While IPED users often dissociate themselves from psychoactive drug users, polydrug use was also commonly reported in our surveys. Users sought to enhance the impact of steroids being used, reduce side effects and combine drugs for recreational and sexual enhancement. This included combining different types of steroids/dietary supplements and or psychoactive substances (such as, but not limited to, cannabis, cocaine and alcohol). As new drugs are added to an existing repertoire of pharmacological substances, the potential for harm increases and further research is needed to explore the often complex interactions of both IPEDs and psychoactive drugs.  

There is a clear public health need to understand how to better engage with IPED users and to better deliver drug and health services to this population to reduce harm and increase access to healthcare. Our research aims to provide evidence to support the delivery of these services through exploring the characteristics and experiences of IPED users and those who work with them. Public health cannot wait for effective prevention interventions to be established and the need for a comprehensive harm reduction approach is required.

Violence is a preventable public health problem and yet there are over one million violent incidents each year in England and Wales, approximately half of which involve alcohol and one quarter of which occur in night time economy environments.  The Trauma and Injury Intelligence Group (TIIG) was established in 2001 to develop an injury monitoring system for the routine data collection and sharing of intentional injuries and unintentional injuries from emergency departments (EDs) across the North West of England.

TIIG data has a particular focus in preventing violence and in 2016/17 the TIIG Lancashire Project conducted in-depth analysis to consider the locations of violent incidents which resulted in an ambulance call-out or an ED attendance. Key to this work was a comparison between patient address geography and incident location geography, in order to understand who was at risk of being a victim or perpetrator of violence. Such intelligence enabled preventative interventions both in areas where individuals were found to be at elevated risk, and in night-time economy areas where violence was occurring.  

Between April 2013 and March 2016 there were 14,427 EDs attendances for assaults by residents of Lancashire; over the same reporting period, there were 6,197 ambulance call-outs for assaults in Lancashire. Yearly ED attendances and ambulance call-outs for assaults decreased over this three-year period. Analyses of TIIG data with secondary data sources revealed that ED attendances for assaults were significantly associated with serious assaults and all types of domestic assaults, while ambulance call-outs for assaults were significantly associated with less serious assaults. An understanding of the nature and likely consequences of attendances and call-outs can help improve the provision of services, and add context to observed trends.

The highest rates of ED attendances for assaults were found in Preston local authority, Blackpool and Blackburn unitary authorities, and were particularly centred in deprived areas. The majority of attendances at EDs for assaults were male (71.3%) and were aged between 15 and 34 years (62.4%); 37.3% were males aged between 15 and 29 years. Similarly, 31.6% of ambulance call-outs for assaults were for males aged between 15 and 29 years.

Where locations were categorised in the ED data, 46.2% occurred in public places, 19.9% occurred at home, 6.2% occurred in places of work, and 6.0% occurred in licensed premises. To a much greater extent than ED data, ambulance call-outs for assaults were clustered in city and town centre night time economy areas, particularly in Blackpool and Preston. Historical TIIG evidence, along with findings from the University of Cardiff, suggest that preventing violence occurring in night time economy environments prevents it happening at all; unlike other problems in public health, violence of this kind is not displaced to another time or location. Licensing work is crucial to reducing this type of violence and making night time economy environments safer and work undertaken in Lancashire has been successful in achieving these objectives in recent years for specific licensed premises.

Both ED attendances and NWAS call-outs were found to be significantly associated with deprivation. The relationship between violence and deprivation is well evidenced and violence shows one of the strongest inequality gradients. Reducing economic equality is a key objective for collaborative partners in order to develop effective strategies to reduce violence. MOSAIC classifies UK households using postcodes based on social group and geodemography and analyses using these classifications were included in this report to further interrogate assault trends in Lancashire. Of the ten Lower Super Output Areas (LSOAs) with the highest rates of ED assault attendances, ‘Renting a room’ was the most common area type. Households within this group include ‘Make Do & Move On’, ‘Disconnected Youth’ and ‘Midlife Stopgap’, all of which are described as ‘single people privately renting low cost homes for the short term’.

This analysis from this report developed the understanding of violence in Lancashire and prompted useful questions and debate between TIIG and the key partners of the project. In Lancashire the application of intelligence is considered at quarterly Pan Lancashire Steering Group meetings attended by public health teams, licensing partners, the police, and data analysts. The meaning derived from these analyses has directed further work and enabled future prevention efforts to be informed by evidence. For further information relating to interventions in Lancashire informed by TIIG data, and their effectiveness, please contact s.j.russell@ljmu.ac.uk.

Related report

Location of violent incidents across Lancashire

The sale of alcohol to drunk people is illegal in the UK. Despite this, drunkenness is a common feature of nightlife settings, while public awareness of the law and bar staff compliance with it appears to be low. In 2013, a pilot study conducted in Liverpool found that 84% of alcohol purchase attempts in nightlife venues by pseudo-intoxicated actors were successful.

Following, presentation of these findings to local partners, the Say No to Drunks pilot intervention was developed and implemented over a five-week period. The intervention aimed to: increase awareness of legislation preventing sales of alcohol to drunks; support bar staff compliance with the law; provide a strong deterrence to selling alcohol to drunks; and promote responsible drinking amongst nightlife users. It included: a social marketing and public awareness raising campaign; bar staff training; police enforcement; and the provision of breathalysers to door supervisors to support entry refusal. An evaluation of Say No to Drunks was undertaken by the Public Health Institute, LJMU, to inform the development of the pilot intervention and provide a baseline for evaluating future work. A range of methods were used including surveys with nightlife patrons, door and bar staff, nightlife observations, and analyses of secondary data sources (e.g. police-recorded crime data). Findings from the evaluation suggested some positive impacts from the Say No to Drunks pilot intervention, including an increase in public knowledge of legislation and improved bar server confidence in refusing sales. Although wider impacts were not observed it was an important first step in designing a body of work to prevent sales of alcohol to drunks and create healthier nightlife environments in Liverpool.

Thus, following the evaluation of Say No to Drunks, the intervention was further refined, broadened and implemented as a second phase in 2015 – rebranded to Drink Less Enjoy More. To inform the continued development of the intervention the Public Health Institute, LJMU, was again commissioned to evaluate this second phase and compare the results to the previous work. Findings from the intervention were extremely positive, suggesting that since Say No to Drunks/Drink Less Enjoy More was implemented nightlife user and bar staff knowledge of the laws around the service of alcohol to drunks significantly increased. Crucially, there was a significant reduction in the proportion of alcohol test purchase attempts leading to a sale of alcohol to a pseudo-intoxicated actor, from 84% (pre-intervention) to 26% (post-intervention). In other words, while only 16% of bar servers refused to serve the intoxicated actors in the 2013 study, this increased to 74% following the Say No to Drunks/Drink Less Enjoy More intervention.

Learning from the pilot phase and subsequent amendments to the intervention, and a greater commitment to implementing all aspects of the intervention, has served to strengthen its impact. The Drink Less Enjoy More intervention is one of the first of its kind in England which aims to address the over service of alcohol to drunks following an evidenced multi-component approach. Importantly, this work is helping to create safer and healthier nightlife environments in Liverpool.

The Public Health Institute is continuing to support local partners, and other area in the UK and Europe, to develop, implement and evaluate multi-component approaches to tackling the sale of alcohol to drunks through various work programmes.

Related reports

• Know the Score pilot evaluation report, March 2016
• Liverpool Drink Less Enjoy More intervention evaluation report, March 2016
• Know the Score pilot evaluation report, July 2015
• Say No To Drunks pilot intervention evaluation report, April 2015
• Ford, K., Quigg, Z., Butler, N., Hughes, K. (2016) The service of alcohol to drunks: Measuring and supporting compliance with the law in Manchester City Centre’s nightlife. Liverpool: Public Health Institute, Liverpool John Moores University.

Information about the number of people who use illicit drugs such as heroin, other opiates or cocaine is a key element of the evidence base used to formulate policy and inform service provision and provides a context in which to understand the population impact of interventions to reduce drug related harm. To direct resources effectively, it is desirable to know about the prevalence of drug use at the local level. To determine the extent to which treatment may reduce harm to communities, it is necessary to know what proportion of the number of drug users in any given area is engaging with treatment. Direct enumeration of those engaged in a largely covert activity such as the use of heroin is not possible and large, household surveys such as the Crime Survey for England and Wales tend to underestimate numbers of those individuals whose drug use is the most problematic and whose lives are often the most chaotic. However, indirect techniques, such as the capture-recapture method and the multiple indicator method can be applied to provide estimates of drug use prevalence.

A team within the Public Health Institute, led by Dr Gordon Hay, has provided estimates of the prevalence of opiate and/or crack cocaine use in England for 2014/15; this has been the 11th set of estimates in a series of studies going back to 2004/05. The team also recently completed a study to estimate the prevalence of opiate use in Ireland, and have previously carried out prevalence studies in Scotland. The team also provides support to researchers carrying out similar studies across Europe.

Alcohol misuse by teenagers continues to be a major problem within the UK, where prevalence (or use) is amongst the highest in Europe. Adolescent drinking has been associated with a wide range of both short- and long-term negative outcomes including problems at school, accidents and injuries, and alcohol dependence. Health professionals have developed interventions that are designed to reduce alcohol misuse and related harms, but research evidence from the UK is limited.

Overview of STAMPP

The National Institute of Health has funded a randomised control trial of the Steps Towards Alcohol Misuse Prevention Program (STAMPP). STAMPP will assess the efficacy of a combined classroom-parental intervention in reducing problematic drinking and alcohol-related harms amongst teenagers. This trial is being undertaken by a collaboration led by the Public Health Institute. 105 post primary schools in Northern Ireland and Glasgow/Inverclyde Education Authority areas have been randomised into intervention and control conditions, with approximately 11,300 teenagers taking part. Children in the intervention group have received a classroom intervention and their parents have also received a brief intervention, while the control group have continued to receive their normal alcohol education.

Classroom intervention

The ‘School Health and Alcohol Harm Reduction Project’ (SHAHRP) was originally developed and delivered in Australia (McBride et al., 2004) and adapted in a culturally appropriate and curriculum consistent manner for the Northern Irish and Glasgow/Inverclyde post primary school context (McKay, McBride, Sumnall and Cole, 2012). SHAHRP combines a harm reduction philosophy with education, skills training and activities designed to encourage positive alcohol-related behavioural change. The programme was delivered in two phases over a two year period by specially trained teachers. Phase 1 was delivered during the second year of post-primary school (when pupils were aged at least 13, which coincides with the onset of alcohol use for many teenagers) and Phase 2 was delivered during the following year. Phase 1 and 2 consist of six and four lessons respectively. Each lesson incorporates the delivery of utility information, skills-based activities and individual and small group discussions to develop an understanding of alcohol-related harm and harm reduction strategies.

Research in Australia found that participation in SHAHRP led to significant positive behavioural effects, including reduced problematic drinking and alcohol-related harms (McBride et al., 2004). A significant increase in knowledge of and safer attitudes toward alcohol was also found (McBride et al., 2004). An adapted version of SHAHRP was implemented in Northern Ireland, beginning in 2005 (McKay et al., 2012). Significant positive behavioural effects, in terms of fewer alcohol-related harms and less problematic drinking, were also found. In comparison to students who received the intervention, students in the control group reported a 45% increase in alcohol-related harms as a result of their own drinking, a 63% increase in alcohol-related harms as a result of other peoples’ drinking, and a 30% increase in the proportion of unsupervised drinkers. Students who received the intervention also reported a 70% increase in alcohol-related knowledge and a 73% increase in healthier attitudes. The programme is now delivered annually to 16,000 students in schools across Belfast and the South Eastern area of Northern Ireland. Repeated assessment of SHAHRP in international settings, and the implementation of SHAHRP in schools and other settings by education and health professionals, has led to the body of work being awarded the 2013 Australian National Drug and Alcohol Award for Excellence Prevention and Community Education.

Parental intervention

The parental intervention is a UK adaptation of an intervention delivered by Koning et al. (2009) in the Netherlands. There are strong links between family behaviour and teenage drinking (Velleman, 2009) and the intervention is designed to help parents/carers establish rules about alcohol use. Parents/carers of intervention students attended a one hour presentation delivered by a trained facilitator. The latest research findings regarding teenage drinking in Northern Ireland and Scotland were outlined in Northern Irish and Scottish schools respectively and the importance of setting strict alcohol use rules was highlighted. Parents were then encouraged to discuss and agree upon alcohol use rules that would be implemented in their home. An information leaflet which contained a summary of the key information from the presentation was posted to the parents two to three months later.

Research in the Netherlands has shown that if a parental intervention which targets rule setting and parents’ attitudes toward alcohol is delivered alongside a school-based curriculum (the Dutch Health School and Drugs programme), it can lead to significantly reduced frequency of drinking or weekly drinking amongst teenagers (Koning et al., 2009).

Data collection

Trial researchers are investigating if STAMPP reduces problematic drinking and alcohol-related harms amongst teenagers. The effect of STAMPP on alcohol-related knowledge and attitudes, as well as a range of psychosocial risk factors for alcohol consumption, are also being examined. STAMPP Trial field workers collected data from teenagers in both the intervention and control groups at baseline, before the delivery of STAMPP began. Follow-up data collection occurred 12 months later, after Phase 1 of SHAHRP had been delivered; and 24 months later, after Phase 2 of SHAHRP and the parental intervention had been delivered. Final data collection will occur 33 months after baseline. If shown to be effective, STAMPP could be implemented on a wider basis in schools across the UK as it is suitable for inclusion in the health and citizenship curriculum.

Project staff

• Principal Investigator and Key Contact: Professor Harry Sumnall – Liverpool John Moores University
• Co-Investigator: Professor David Foxcroft – Oxford Brookes University
• Co-Investigator: Professor Jonathan Cole – University of Liverpool
• Co-Investigator: Dr Andrew Percy – Queen's University Belfast
• Co-Investigator: Lynn Murphy – Northern Ireland Clinical Trials Unit
• Trial Manager: Dr Michael McKay – Liverpool John Moores University
• Research Assistant: Séamus Harvey – Liverpool John Moores University
• Trial funded by The National Institute for Health Research - Public Health Research Programme

The North West HIV and AIDS monitoring unit was established in 1995 and is Public Health Institute’s longest running public health monitoring system. The unit collects data annually on the treatment and care of HIV positive individuals in the North West of England from 39 treatment centres including genitourinary medicine, infectious disease units, and specialist haematology and paediatric units. This is supplemented by data from voluntary agencies and social service departments providing additional support to HIV positive individuals outside of their routine medical care.

Data collected by the unit forms part of the national Survey of Prevalent HIV Infections Diagnosed (SOPHID) conducted by the Health Protection Agency. In addition, further demographic, behavioural and treatment information is also collected, and these data have been decided in consultation with local commissioners in order to meet local service planning and policy development needs.

The Public Health Institute produces an annual report on HIV and AIDS in the North West of England, which is circulated to sexual health commissioners, clinicians and public health specialists across the North West and is acknowledged within the sexual health community as the most comprehensive source of regional HIV information. In addition, interactive web tables are produced to allow commissioners to extract specific data at a local authority and primary care trust level and this data is routinely used to inform the development of Joint Strategic Needs Assessments, Sexual Health Needs Assessments and the commissioning of services for a range of population groups across young people and adult services.

The HIV and AIDS monitoring work is guided by a steering group of local commissioners and developed to meet local planning needs. Most recently the Institute has developed an interactive online mapping tool which maps HIV prevalence at middle super output area (MSOA) geography. This allows for the planning of targeted prevention strategies and service provision. The tool is currently being used by the Cheshire and Merseyside Late Diagnosis Action Planning Group to identify specific areas where targeted prevention and universal opt-out testing should be considered, and the tool has been used by the National AIDS Trust (NAT) as a case study of best practice in low prevalence areas.

The Public Health Institute’s HIV and AIDS monitoring work is a strong example of the way the Institute provides a long term monitoring service which maintains consistent and high quality data provision whilst responding to changing epidemiological trends and regional commissioning needs.