The Lancet. Public health最新文献

There is increasing public health concern about harmful gambling, but no consensus on effective policies and interventions to reduce risk and prevent harm has been reached. Focusing on policies and interventions (ie, measures), the aim of this study was to determine if expert consensus could be reached on measures perceived to be effective that could be implemented successfully. Our work involved a pre-registered, three-round, independent Delphi panel consensus study and an implementation rating exercise. A starting set of 103 universal and targeted measures, which were sourced from several key resources and inputs from public health stakeholders, were grouped into seven domains: price and taxation; availability; accessibility; marketing, advertising, promotion, and sponsorship; environment and technology; information and education; and treatment and support. Across three rounds, an independent panel of 35 experts individually completed online questionnaires to rank each measure for known or potential effectiveness. A consensus was reached if at least 70% of the panel judged a measure to be either not effective, moderately effective, or highly effective. Then, each measure that reached a consensus for effectiveness was evaluated on four implementation dimensions: practicability, affordability, side-effects, and equity. A summative threshold criterion was used to select a final optimal set of measures for England. The panel reached consensus on 83 (81%) of 103 measures. Two measures were judged as ineffective by the panel. The remaining 81 effective measures were drawn from all domains (14 of 15 measures in the the marketing, advertising, promotion, and sponsorship domain were judged as effective, whereas five of ten measures in the information and education domain were judged as effective). During the evaluation exercise, the 81 measures were assessed for likelihood of implementation success. This assessment considered the practicality, affordability, ability to generate unanticipated side-effects, and ability to decrease differences between advantaged and disadvantaged groups in society of each measure. We identified 40 universal and targeted measures to tackle harmful gambling (three measures from the price and taxation domain; ten from the availability domain; five from the accessibility domain; six from the marketing, advertising, promotion, and sponsorship domain; eight from the environment and technology domain; three from the information and education domain; and five from the treatment and support domain). Implementation of these measures in England could substantially strengthen regulatory controls while providing new resources. The findings of our work offer a blueprint for a public health approach to preventing harms related to gambling.

Stroke can be prevented through effective management of risk factors. However, current primary stroke prevention approaches are insufficient and often fragmented. Primary stroke prevention strategies are predominantly targeted at behavioural (eg, smoking cessation and lifestyle modifications) and pharmacological interventions (ie, prevention medications). There is also a need to consider interrelating structural factors that support, or hinder, prevention actions and behaviours of individuals. Without addressing these structural factors, it is impossible to maximise the benefits of behavioural and pharmacological interventions at the population level. We propose a tripartite approach to primary stroke prevention, comprising behavioural, pharmacological, and structural interventions, which is superimposed on the socioecological model. This approach could minimise the current fragmentation and inefficiency of primary stroke prevention.

Background: Parental death and its anniversaries, including anticipation of these dates, might cause distress and increase the risk of substance use disorder and suicide-related behaviour in bereaved adolescents and young adults. We examined whether the risk of substance use disorder and suicide-related behaviour increases around the date of parental death and subsequent anniversaries.

Methods: Using Swedish national registers, we conducted a cohort study of individuals aged 12-24 years. We included individuals aged 12-24 years between Jan 1, 2001, and Dec 31, 2014, whose parents were alive at entry (n=1 858 327) and followed up with them until the end of age 24 years. We excluded individuals with a half-sibling, a history of emigration, a previous record of the outcome events, a parental death before study entry, two parental deaths on the same day during the follow-up, or missing data for relevant variables. Follow-up ended on the day of an outcome event or on Dec 31, 2014; at age 25 years, emigration, or death; or a year before the second parental death. We studied substance use disorder and suicide-related behaviour outcomes separately and included non-fatal and fatal events in both outcomes. We used Cox regression to estimate hazard ratios (HRs), controlling for baseline psychiatric, demographic, and socioeconomic characteristics. Parental death was modelled as a time-varying exposure over 72 monthly periods, starting from 1 year before the parental death to the fifth year and later after the death. Unmeasured confounding was also addressed in within-individual comparisons using a case-crossover design.

Findings: During follow-up (median 7·5 [IQR 4·3-10·6] years), there were 42 854 substance use disorder events, with a crude rate of 3·1 per 1000 person-years. For suicide-related behaviour, there were 19 827 events, with a crude rate of 1·4 per 1000 person-years. Most of the events studied were non-fatal. In the month of parental death, the HR for substance use disorder risk was 1·89 (95% CI 1·07-3·33) among male participants, and, for suicide-related behaviour, was 3·76 (1·79-7·89) among male participants and 2·90 (1·61-5·24) among female participants. In male participants, there was an increased risk around the first anniversary (substance use disorder: HR 2·64 [95% CI 1·56-4·46] during the anniversary month; 2·21 [1·25-3·89] for the subsequent month; and for suicide-related behaviour: 3·18 [1·32-7·66] for the subsequent month). Among female participants, an increased risk of substance use disorder recurred around every year consistently in the month before the anniversary of the death and there was an increased risk for suicide-related behaviour in the months of the first and second anniversaries.

Interpretation: Although effect sizes were large in this cohort study, the number of individuals who had the outcomes was small. Nevertheless, adolescents an