Self-help interventions without professional contact to curb adult problem drinking in the community are increasingly being delivered via the Internet.The objective of this meta-analysis was to assess the overall effectiveness of these eHealth interventions.In all, 9 randomized controlled trials (RCTs), all from high-income countries, with 9 comparison conditions and a total of 1553 participants, were identified, and their combined effectiveness in reducing alcohol consumption was evaluated by means of a meta-analysis.P = .04) emerged between single-session personalized normative feedback interventions  and more extended e- self-help .An overall medium effect size  was found for the 9 studies, all of which compared no-contact interventions to control conditions. The medium effect was maintained  after exclusion of two outliers. Type of control group, treatment location, type of analysis, and sample size did not have differential impacts on treatment outcome. A significant difference (E-self-help interventions without professional contact are effective in curbing adult problem drinking in high-income countries. In view of the easy scalability and low dissemination costs of such interventions, we recommend exploration of whether these could broaden the scope of effective public health interventions in low- and middle-income countries as well. Single session e-personalized normative feedback is a phrase used to describe a brief type of self-help delivered over the Internet. Personalized feedback refers to the provision of individualized observations on each drinker’s alcohol consumption patterns in comparison with the recommended low-risk drinking guidelines. Normative feedback is often an important component of these interventions, enabling problem drinkers to compare their own alcohol use  to the level of their own cohort or peer group  code Z72.1) is a pattern of heavy drinking and/or binge drinking that carries with it a risk of harmful consequences to the drinker. These consequences may be detrimental to physical or mental health, or have adverse social consequences to the drinker or others. Other potential consequences include worsening of existing medical conditions or psychiatric illnesses, injuries caused to self or others, due to impaired judgment after drinking, high risk sexual behavior while intoxicated, and worsening of personal or social interactions.Hazardous use (ICD-10 code F10.1) is a pattern of drinking that is causing damage to health. The damage may be either physical  or mental . Harmful patterns of use are often criticized by others and are sometimes associated with adverse social consequences of various kinds. Harmful drinking has persisted for at least 1 month or has occurred repeatedly over the past 12-month period; subject does not meet criteria for alcohol dependence.Harmful drinking (ICD-10 code F10.2) is defined as drinking that meets at least 3 of the following criteria: tolerance; withdrawal symptoms; impaired control; preoccupation with acquisition and/or use; persistent desire or unsuccessful efforts to quit; sustains social, occupational, or recreational disability; use continues despite adverse consequences.Alcohol dependence , Science Citation Index Expanded, Social Sciences Citation Index, Arts and Humanities Citation Index (1997 to present), CINAHL, EMBASE, the Cochrane Drug and Alcohol Group Specialized Register, the Cochrane Effective Practice and Organization of Care (EPOC) Group register, the Alcohol and Alcohol Problems Science Database, and ETOH . Searches were conducted with keywords and text words, in which words indicative of eHealth interventions  were combined with terms indicative of alcohol disorders  and our target group (adults). Those search strategies were combined with the optimal search strategy for randomized controlled trials (RCTs) designed by the United Kingdom Cochrane Centre (Cochrane Collaboration 2008). We also scanned Dissertation Abstracts and Digital Dissertations to cross-check references relating to earlier meta-analyses and systematic reviews on eHealth interventions, brief interventions, and e-self-help interventions for problem drinking as well as unpublished literature. Reference lists of retrieved papers were screened, and papers that possibly met inclusion criteria were retrieved and studied . No langIn this meta-analysis, we included only those studies that examined e-self-help interventions for adult problem drinkers (aged 18 or older). Studies on e-self-help interventions targeting student populations in college and university settings were excluded, as their effectiveness has been reported in other reviews and meta-analyses ,26. FromOur initial selection from the first search was based on information derived from titles, abstracts, and keywords; if these yielded insufficient information to assess the inclusion criteria, then the full paper was retrieved. All papers excluded at this stage were independently assessed on their inclusion criteria by two independent raters (authors BB and HR) to ensure an error-free selection procedure. In addition, two independent coders, authors VS and HR, assessed the effect sizes and moderator variables of the included studies; any disagreement was resolved by discussion and consensus .Some 25 scales are available to assess the validity and quality of RCTs . As ther1 – m0) / SD, where m1 and m0 are the mean scores in the experimental and control conditions.We first examined the effects of e-self-help interventions for problematic alcohol use in comparison with control conditions. The usual approach is to calculate the standardized mean difference, also known as Cohen’s d (the mean difference divided by the pooled standard deviation) that is, d = (m1–1]S1                    2 + [n0–1]S0                    2) / (n1 + n0 –2) where n1 and n0, and S1 and S0 are the sample sizes and variances of the experimental and control groups as obtained from the primary study. As this effect size d is subject to small-sample bias, it can be adjusted by using a scaling factor, which is multiplied by d to arrive at Hedges’ bias-corrected effect size g, where g = d (1– [3/4(n1 + n0] –9).The pooled standard deviation (SD) is defined as SD = √  to calculate effect sizes. If more than one measure was used in a single primary study, then the mean of the effect sizes was calculated so that each study was represented with only one effect size in our meta-analysis. In one study  in 9 months .P = .04) emerged between e-single-session personalized normative feedback interventions (g = 0.27) and e-self-help interventions of a more extended nature (g = 0.61). This suggests that the latter may be more effective. Effects of the interventions beyond 9 months could not be assessed; one study reported 12-month follow-up results, and these suggested cost-effectiveness but a fade-out of the effect obtained at 6 months [We found a medium effect size (g = 0.39) for eHealth interventions to reduce adult problem drinking in the general population up to 6 or 9 months posttreatment, as compared with no intervention. A significant difference . Although some may argue that this is not a viable option given the low Internet penetration in such countries, we would point out that such arguments abounded in high-income countries at the start of the millennium when e-self-help interventions for hazardous drinking were first being introduced. Meanwhile, the digital divide in Internet access between the more and less affluent countries is narrowing. In fact, one in four people worldwide now have Internet access . Some e-Our study has sought to synthesize the available evidence about the effectiveness of no-contact e-self-help interventions in curbing adult problem drinking. The data suggest that these are effective. Our findings also highlight the need for more evaluations of the clinical outcomes and the cost-effectiveness of online screening instruments and interventions. The paper of Smit and colleagues in this issue indeed illustrates the economic benefits of e-self-help interventions for curbing adult problem drinking . Future


Pathogenic intestinal protozoa infections are common in school-aged children in the developing world and they are frequently associated with malabsorption syndromes and gastrointestinal morbidity. Since diagnosis of these parasites is difficult, prevalence data on intestinal protozoa is scarce.We collected two stool samples from school-aged children on Pemba Island, Tanzania, as part of a randomized controlled trial before and 3 weeks after treatment with (i) single-dose albendazole (400 mg); (ii) single-dose nitazoxanide ; (iii) nitazoxanide-albendazole combination , with each drug given separately on two consecutive days; and (iv) placebo. Formalin-fixed stool samples were examined for the presence of intestinal protozoa using an ether-concentration method to determine the prevalence and estimate cure rates (CRs).Giardia intestinalis, Entamoeba histolytica/E. dispar and Blastocystis hominis. Observed CRs were high for all treatment arms, including placebo. Nitazoxanide showed a significant effect compared to placebo against the non-pathogenic protozoon Entamoeba coli.Almost half (48.7%) of the children were diagnosed with at least one of the  pathogenic protozoa Intestinal protozoa infections might be of substantial health relevance even in settings where they are not considered as a health problem. Examination of a single stool sample with the ether-concentration method lacks sensitivity for the diagnosis of intestinal protozoa, and hence, care is indicated when interpreting prevalence estimates and treatment effects. Entamoeba histolytica and Giardia intestinalis) result in considerable gastrointestinal morbidity, malnutrition and mortality worldwide, particularly among young children in developing countries [E. histolytica, the causative agent of amoebiasis, kills between 40,000 and 100,000 people each year; hence, is one of the deadliest parasitic infections worldwide [G. intestinalis affects an estimated 28.5 million people every year [G. intestinalis has been estimated at 2–3% in the industrialized world and 20–30% in developing countries [Cryptosporidium spp. is another major causal agent of diarrhoea, primarily affecting immunocompromised individuals such as those infected with HIV [Blastocystis hominis is a common additional anaerobic intestinal protozoon and its pathogenicity is still under debate [Infection with pathogenic intestinal protozoa , and the Ministry of Health and Social Welfare of Zanzibar  and is registered at Current Controlled Trials . Participating in the trial required written informed consent from parents or legal guardians and oral assent from children. Parents and children were counseled that participation is voluntary and withdrawal was possible at any time without specification of reasons and further obligations. At the end of the trial, all children who were diagnosed with soil-transmitted helminths received albendazole .Details of the study area, population and procedures have been described previously . In brieApproximately 2 g of stool were fixed in 10 ml of 5% formalin in Falcon tubes labeled with unique identifiers. Stool samples were thoroughly broken down and homogenized with a wooden spatula. The formalin-fixed samples were transferred to the Swiss Tropical and Public Health Institute  and examined within 10 months.g. The supernatant was discarded. To the remaining pellet, 7 ml of physiological NaCl-solution and 2–3 ml of diethyl ether was added. Tubes were shaken and centrifuged again for 3 min at 500 g. The upper three layers were discarded. The entire sediment was examined by experienced laboratory technicians under a microscope for soil-transmitted helminths at a magnification of 100×, and intestinal protozoa at a magnification of 400× or 500× using oil immersion. The current analysis focuses on intestinal protozoa, including the pathogenic intestinal protozoa G. intestinalis and E. histolytica/E. dispar ; the pobütschlii,23. Cryp method . Infecti method .Data were double-entered into an Excel file (Microsoft 2010) and cross-checked. Statistical analysis was performed using Stata version 10.1 .x2 test. In the baseline prevalence analyses, the odds of being infected with a specific intestinal protozoon species for boys compared to girls and for children from Wawi compared to Al-Sadik school was calculated using logistic regression.The prevalence of intestinal protozoa was determined before treatment (baseline) and at the 3-week post-treatment follow-up. Differences between prevalence at baseline and follow-up were assessed using Cure rates (CRs) were estimated for each intestinal protozoon species for the different treatment arms as the percentage of positive children at baseline diagnosed negative after treatment. Differences in CRs among treatment arms were examined using logistic regressions. Reduction of infection intensity was assessed as the difference in infection intensities before and after treatment among all individuals . Mean of differences in infection intensities was calculated for each treatment arm and for each intestinal protozoon species together with 95% confidence intervals (CIs). Decrease in infection intensity was assumed as significant when 95% CI was below 0.E. histolytica/E. dispar and G. intestinalis was 18.0% and 16.4%, respectively before treatment  were infected with at least one of the three  pathogenic intestinal protozoa. The prevalence of G. intestinalis, E. histolytica/E. dispar and B. hominis at the 3-week post-treatment follow-up was 17.3%, 16.4% and 31.1%, respectively  and all intestinal protozoa combined (p = 0.046) showed significantly lower prevalence at follow-up compared to baseline.Examination of the follow-up stool samples revealed the following prevalences: 49.8% of children remained infected with at least one of the three  pathogenic intestinal protozoa and 69.3% of the children were found positive for at least one intestinal protozoa. The prevalence of p <0.1) that girls were at a higher odds of being infected with E. coli than boys . Children from Wawi school had significantly lower odds of being infected with B. hominis , E. nana  and I. bütschlii  considering only the baseline stool sample than children from Al-Sadik. Additionally, there was a trend (p <0.1) that children from Wawi school had a lower odds of being infected with G. intestinalis  and any of the three  pathogenic intestinal protozoa combined .The odds of being infected with any intestinal protozoa at baseline was significantly higher for girls than boys (odds ratio (OR) = 1.97; 95% CI 1.32–2.93) . The lowest CR among the antiparasitics tested was documented for single-dose albendazole against E. coli . Note that the group of children receiving placebo had moderate to high CRs against intestinal protozoa infections. Comparing the outcomes among treatment arms using logistic regression revealed that single-dose nitazoxanide had a significant effect on E. coli . Furthermore, we observed a trend (p <0.1) with the combination of nitazoxanide plus albendazole against E. nana . All other results of the logistic regressions revealed p-values above 0.1; hence, there was no significant effect compared to placebo.Observed CRs were moderate to high for all intestinal protozoa regardless of the treatments administered Table . The higE. histolytica/E. dispar  and E. coli  and in the nitazoxanide single-dose treatment against E. coli infection intensity .Comparing the mean intensity of intestinal protozoa infection before and 3 weeks after treatment in the different arms revealed no significant effect for most of the assessed intestinal protozoa (results not shown). The only significant reductions of infection intensity (95% CI below 0) were observed in the albendazole-nitazoxanide combination against T. trichiura and other soil-transmitted helminths. This trial found low CRs against soil-transmitted helminth species[Since very little is known on the epidemiology of intestinal protozoa in sub-Saharan Africa, we analyzed formalin-fixed stool samples obtained from 550 school-aged children who participated in a randomized controlled trial on Pemba Island to assess the efficacy and safety of nitazoxanide, albendazole and a combination of both drugs against  species. ImportaOur results confirm that intestinal protozoa are a public health issue on Pemba Island. Indeed, almost half of the children were infected with at least one of the three  pathogenic intestinal protozoa. When considering the results from the baseline and the 3-week post-treatment follow-up, assuming that a child who was diagnosed positive at follow-up was diagnosed as a false-negative case at baseline, the prevalence of intestinal protozoa infection was even higher Figure . This isE. histolytica is frequently misdiagnosed, even by experienced laboratory personnel [A recent study reported only moderate sensitivity for the ether-concentration technique compared to the FLOTAC technique when examining the same formalin-fixed stool samples . Howeverrsonnel .et al., in a study carried out in school-aged children in Côte d’Ivoire, reported a considerably higher prevalence of intestinal protozoa among boys than girls [et al. from Mexico, where boys were at higher odds of a G. intestinalis infection that girls [We found that girls were generally at higher odds of an infection with any of the intestinal protozoa encountered than boys. Similar results were found by Mohammed Mahady and colleagues in Malaysia . On the n girls , corrobot girls . Other st girls . These fG. intestinalis[G. intestinalis, E. histolytica/E. dispar and the potentially pathogenic B. hominis. A further limitation is the relatively small number of positive children for specific intestinal protozoa. Infection intensity did not significantly decrease after treatment with the exception of E. coli in the nitazoxanide group. Note that intestinal protozoa multiply within the host, which can also influence infection intensity results [Intestinal protozoa often co-occur with intestinal nematodes and it is therefore important to determine whether anthelminthic and other antiparasitic drugs have an effect on concomitant intestinal protozoa infections. Albendazole, for example, was found in a recent meta-analysis to be as effective as metronidazole against estinalis. The obsresults . Furtherresults -40. The Our study revealed that intestinal protozoa infections are highly prevalent among school-aged children on Pemba Island, a setting where these intestinal protozoa were not considered of major importance thus far. The difficulty in accurately diagnosing intestinal protozoa infections, also experienced in our study, might be one of the chief reasons why these pathogens and the diseases they cause are often neglected, even in settings where mass treatment are underway against intestinal helminth infections . The preNone of the authors has any conflict of interest concerning the work reported in this paper.BS, ShMA, SaMA, JU, MA and JK designed the study; BS, HM, ShMA, SaMA, and JK implemented the study; BS managed the data; BS, HM, IIB, JU and JK analyzed and interpreted the data; BS wrote the first draft of the paper; HM, ShMA, SaMA, IIB, JU, MA and JK revised the manuscript. All authors read, and approved the manuscript prior to submission and assisted with the final revision of the manuscript.


P < 0.05). The results of the RCT demonstrated that students who had seen the video were better able to apply the technique, resulting in a better performance. The video, therefore, represents an important tool to refresh and reinforce previous learning.The Undergraduate Nursing Course has been using videos for the past year or so. Videos are used for many different purposes such as during lessons, nurse refresher courses, reinforcement, and sharing and comparison of knowledge with the professional and scientific community. The purpose of this study was to estimate the efficacy of the video  as an instrument to refresh and reinforce nursing techniques. A two-arm randomized controlled trial (RCT) design was chosen: both groups attended lessons in the classroom as well as in the laboratory; a month later while one group received written information as a refresher, the other group watched the video. Both groups were evaluated in a blinded fashion. A total of 223 students agreed to take part in the study. The difference observed between those who had seen the video and those who had read up on the technique turned out to be an average of 6.19 points in favour of the first ( Videos are widely used for supporting and stimulating student comprehension in various contexts: in the classroom, in the laboratory and in distance education –3. EducaEasy access to the web allows the scientific community to acknowledge and promote the exchange of opinions . Skiba dSome authors are concerned about the risk that the use of computers will belittle rather than to improve education; moreover, they argue whether the use of technology will ever be able to replace the fundamental role of the teacher in student learning. Despite this, many studies suggest that the use of technology and internet is a useful instrument which favours education , 8, 9.In the literature, various observational studies have demonstrated that the use of video streaming contributes to learning as a powerful instrument for education and for the acquisition of clinical competencies, reducing the gap between theory and practice –12. It hThe benefits of using videos are well documented and videos are considered a valid tool for student education –22. PartCurrently, there are few experimental studies which demonstrate video effectiveness applied to traditional nursing techniques –26. StudIndications of better video use have been analyzed by various experts, in particular by Race and Shephard –3. Two kThe advantage of using YouTube clearly emerges as an instrument for sharing videos and allowing students to participate actively in the discussion on films. YouTube has grown during the last few years and is visited by almost 70 million persons a day. With their free access, the main search engines worldwide  allow comparisons among the entire professional and scientific community, thus offering the possibility to comment and make suggestions, and for free and constructive debate, therefore becoming a reliable and updated point of reference. It is a powerful instrument which makes sharing and exchanging ideas possible .Videos are surely among the most interesting technologies, adding value to learning content. Not only should the image be detailed, but it should offer students the possibility to use more channels, thus enhancing and facilitating learning processes.However, there is little evidence on the efficacy of video streaming to support student learning. The aim of this study is to verify the effectiveness of video streaming as an instrument for refreshing and reinforcing nursing education.A two-arm RCT design was chosen and performed in December 2009 at the Undergraduate Nursing Course at Turin University. This is a two-group design: subjects were randomly assigned to the experimental and control groups. Both groups attended lessons in the classroom as well as in the laboratory; a month later the control group received written information to refresh the technique, while the experimental group saw the video. Both groups were given ten minutes to allow them to freshen up on the technique. Students were assessed individually by a blinded evaluator using observational rating scales.The population consisted of 250 undergraduate students attending the nursing course at Turin University.Students who consented to participate in the study were fully informed about their right to withdraw at any time and the fact that data were to undergo aggregate processing and would be stored safely.Participants were randomized by a computer-generated randomization scheme and the identification number from the randomized allocation schedule. Students were not told whether they would be seeing the video or reading up on the technique. To guarantee the effective homogeneity between the two groups, data variables influencing student performance, such as age, sex, qualifications, laboratory participation, reading information concerning the technique and development of a working activity in the field, were collected.The video chosen involves the technique dealing with ‘moving an uncooperative patient from the supine to the lateral position’. The health care professional uses a sliding sheet to move a mobility-impaired person. The written information was compared with the video, which turned out to be identical regarding both the words and the sequence. The duration of the video was 7.32 min.The appraisal instrument was an observational grid developed to assess student performance. The instrument was a 33-item observational form with the possibility to mark whether a single action had been carried out or not. Each item expresses single actions which together make up the technique (e.g. inform the patient about what is going to happen/wrap the cloth around both shoulders/lift the edge of the bed…). Less important items were given 1 point whereas core items were given 2 points. The assessment forms were anonymous and were identified through a code assigned at the time of enrolment.Performance was evaluated based on the weighted sum of all the actions making up the procedure.A pilot study was carried out in May 2009 on 21 students with the aim of identifying potential shortcomings, testing the appraisal instrument for the collection of information and assessing the sample size necessary to perform the RCT.Considering the measuring instrument could supply a range of values between 0 and 53 and taking 5 as the minimum significant value which we would observe, we needed to enrol 100 students for each arm of the study for an 80 % statistical power.t test was used for variables normally distributed, while the Mann–Whitney test was used if the variable showed a non-normal distribution . All tests were conducted at a significance level of 5 %. The data collected were placed on Excel spreadsheets and analyzed with the Stata 9 statistical programme.The items that made up the technique were treated as qualitative variables: actions not performed vs actions done correctly. In comparing the experimental and control groups for qualitative variables, the Pearson’s Chi-square or the Fisher’s exact test were used: in particular, the latter was used if at least one cell showed less than five expected values. The Shapiro–Wilk test was performed to assess the normal distribution of quantitative variables: the Student’s n = 112) and the control group .Altogether, 223 students joined the study: 74 males and 129 females. They were randomized into the experimental group , so viewing the video led to a better performance in comparison with simply reading up on the technique.The difference between the two groups was statistically significant (What emerges according to the data we obtained is that videos are beginning to draw serious attention to their learning potential. The result of this study is in conformity with the other experimental studies present in the literature –26. We aThe possibility of interrupting the film and seeing some sections again offers the advantage of maintaining a high attention level. However, this means that the user should be able to easily access and view the contents. Therefore, it is necessary for users to simply surf the Net, review, observe and retrieve the material of their choice. As described in the literature, and in particular by Bennet , studentVarious descriptive studies and opinions of experts assert that the video represents an important opportunity for the student to increase and support learning, thus contributing to a better performance of the technique. But the video cannot completely replace face-to-face lessons, although it widely contributes to and complements education . The vidDuring the last few years, university education has undergone profound changes in the organisation and methodologies used. Video use and video streaming represent one of these instruments. What emerges from the results of this study is that videos are useful tools for refreshing and reinforcing concepts learnt during nursing courses. The use of educational videos could become a routine instrument for student training. A limitation of the research is the possibility that respondents in the intervention group sought more information on their own. A second limitation is that the difference between the two groups could be a short-term effect, because the refresher training was immediately followed up by the assessment. Follow-up research could explore the permanence of the effect of using video as a tool for refresher training.The aim of the study is to verify the effectiveness of the video as an instrument for refreshing and reinforcing nursing education.The University’s need to provide a useful tool for students.The use of the video contributes to refresher training as a powerful instrument for the education and the acquisition of clinical competencies,The use of educational videos could become a routine instrument for student training.


This study examined the effectiveness of Motivational Interviewing (MI) to reduce hazardous drinking among patients in treatment for depression. The sample consisted of 307 participants ages 18 and over in depression treatment in Kaiser Permanente outpatient psychiatry who reported hazardous drinking, illegal drug use or misuse of prescription drugs in the prior 30 days, and who scored ≥ 5 on the Patient Health Questionnaire (PHQ-9). Participants were randomized to receive either 3 sessions of MI or printed literature about alcohol and drug use risks, as an adjunct to usual outpatient depression care. Preliminary analyses examined baseline group differences and outcomes among the 264 participants who completed 3- month follow-up to date. In the 3 month follow-up sample, both groups showed reduction in hazardous drinking and depression. Among participants reporting any hazardous drinking at the 4+/5+ level at baseline (N=154), MI-treated participants were less likely than controls to report hazardous drinking at 3 months, at a level approaching statistical significance . No group differences in cannabis use reduction or depression reduction were observed. This study examined preliminary data regarding the efficacy of MI (intervention) versus printed literature on alcohol use risks (control) among depression patients in a clinical setting as a supplement to usual care in psychiatry. Initial findings indicate that both groups reduced hazardous drinking at 3 months, but that MI may be somewhat more effective among participants drinking at a 4+/5+ level. The investigators are in process of completing 3-, 6- and 12-month follow up. Further analyses will examine long term outcomes, outcomes among subgroups based on drinking and psychiatric severity, predictors of hazardous drinking reduction in the sample as a whole, initiation with specialty alcohol and drug treatment among dependent participants, and cost effectiveness of the intervention.


It is important to keep recall rates to a minimum. At the Jarvis Centre daily arbitration is performed by two experienced film readers, a regular pair each weekday. Observation that different arbitration pairs have varying thresholds for recalling round masses prompted this audit.Thirty-six digital cases with round masses were selected during arbitration over a 1-month period. All cases were anonymised and re-arbitrated by six pairs of arbitrators who usually work together. The pairs included at least one film reader with over 10 years experience. Specific mammographic features and the final audit recall decision were recorded.A total 17/36 (47%) cases were recalled at the original arbitration. Arbitration pairs had different audit recall rates ranging from 39 to 81%. All arbitrators agreed to either rescreen or recall in 1/3 of cases. Results showed there was variation in both perception of mammographic features present and the importance given to other factors such as age, multiplicity, lesion location and density; affecting recall even in the presence of benign mammographic features.There is considerable variation in opinion between arbitration pairs due to the complex nature of interpreting which mammographic features are present and balancing these against other factors such as age, multiplicity, lesion location, and density. It is useful to reflect on the steps in the decision-making process to understand the science behind the art in an attempt to achieve more consistency between pairs and keep recall rates down.


Aims: The aim of the study was to explore associations between dimensions of alcohol use in married couples and subsequent divorce in Russia using longitudinal data. Methods: Follow-up data on 7157 married couples were extracted from 14 consecutive annual rounds (1994–2010) of the Russian Longitudinal Monitoring Survey, a national population-based panel study. Discrete-time hazard models were fitted to estimate the probability of divorce among married couples by drinking patterns reported in the previous survey wave. Results: In adjusted models, increased odds of divorce were associated with greater frequency of husband and wife drinking , wife's binge drinking (P = 0.05) and husband's heavy vodka drinking (P = 0.005). Couples in whom the wife drank more frequently than the husband were more likely to divorce , compared with other combinations of drinking. The association between drinking and divorce was stronger in regions outside Moscow or St. Petersburg. Conclusion: This study adds to the sparse literature on the topic and suggests that in Russia heavy and frequent drinking of both husbands and wives put couples at greater risk of future divorce, with some variation by region and aspect of alcohol use. Alcohol use in Russia is a major public health concern  (http://www.cpc.unc.edu/projects/rlms-hse). At the beginning of phase 2 (1994), a three-stage probability sample was chosen. The final sample consisted of 4718 dwellings, of which 84.3% completed interviews (lower in the Moscow/St. Petersburg regions (60.2%)). According to the RLMS survey team, the population sampled in wave 5 (1994) compared well with the 1989 census population in terms of distribution of household size, sex, age and urban-rural residence. Divorce rates in the RLMS were slightly lower than national rates, but followed the same pattern over time.Full details on RLMS design and sampling are available on the website  was defined if At each wave, participants were asked about drinking frequency, beverage types they consumed and the maximum daily volume of each beverage consumed in the 30 days before interview. The drinking information collected in each wave was used as the exposure variable for the follow-up period ending at the next wave.Frequency of drinking was categorized into groups: abstained/2–3 times a month/weekly/2–3 times a week/4+ times a week. We also derived a ‘drinking pattern’ variable which classified individuals into binge drinkers, non-binge drinkers or abstainers. Binge drinking was defined as consuming >80 g of ethanol from a single type of beverage on a single occasion, a cut-off used in previous studies in Russia , wife frequent drinker and husband not; husband frequent drinker and wife not or both frequent drinkers. The same was done for drinking pattern concordance but with binge drinking instead of frequent drinking.From previous studies , severalAll covariate data were self-reported and taken from the start of each interval. We included individual level variables for both spouses  and couple-level variables . A binary variable identified whether the couple had resident young (<18 years) biological children. Exact age was divided into 10-year groups; and education had three categories: incomplete secondary; secondary, specialist and professional; and university level and above. Employment status had three categories: unemployed; employed and ‘other’—including students, housewives, etc. Household income was adjusted for equivalized household size, using the OECD-modified scale  assumption , and theThe follow-up rate of couples between successive waves ranged from 83 to 93% Table . Couple Over the 15 time intervals, 344 divorces were observed. Couples who divorced were significantly younger and more likely to live in Moscow or St. Petersburg and to be childless. Individual factors associated with divorce were either party drinking at least twice a week or having poor life satisfaction, wife's binge drinking and wife's poor self-assessed health. No associations were seen with education, employment or economic security. Divorce was lowest when both were non-frequent drinkers or non-binge drinkers. Husbands drank more frequently, were less likely to abstain and were more likely to binge drink than wives (tabulations not shown). Almost half (47%) of husbands were binge drinkers compared with only 10% of wives. As has been found in previous research (Table P = 0.002), having a very strong association in Volga and the North Caucasus, but weaker or reverse effects in Moscow or St. Petersburg , the adjusted odds of divorce at follow-up were twice as high as those of a light spirit drinker. Couples in whom the wife drank frequently, or was a binge drinker, were associated with higher odds of divorce. After adjustment for husband's drinking, the association with frequency attenuated, but the odds for binge drinking remained significant. The positive trend between divorce and spirit consumption was not found when beer and wine consumption on a single occasion were considered, but there was some evidence that women drinking over 20 g of ethanol as beer had an increased risk of divorce (results not shown). We experimented with using gender-specific cut-offs to identify binge drinking , but this made little difference to the results. The effect of male drinking frequency varied significantly by region (P = 0.19), regressions using the constructed variable showed that couples in whom the wife drank more frequently had higher odds of divorce than any other category.Although the interaction between husband's and wife's drinking was non-significant  showed no substantial differences. We show results from a complete case analysis as the analysis using multiple imputation showed the same pattern of association.We have found that in a large population-sample of married couples in Russia, regular drinking and binge drinking by either spouse were independently associated with an increased risk of subsequent divorce, relative to couples who drank moderately. There was a dose–response effect with the risk of divorce increasing with frequency and usual volume of spirits drunk by the husband on a single occasion. This effect was not accounted for by age, life satisfaction, children, health or socio-economic factors. Discordant spousal drinking patterns were associated with higher odds of divorce only when the wife drank more frequently. This may relate to the norms of Russian drinking culture where heavy drinking is considered socially acceptable for men, but not for women . However, small numbers prohibited further exploration. The variation is unlikely to be explained by differential response rates between regions, because results using multiple imputation showed the same pattern of association.There were some limitations related to the survey questionnaire. Firstly, alcohol was measured by self-report, where under-reporting is likely. However, provided that under-reporting remains constant over time, this should not bias our associations. Secondly, binge drinking may be underestimated as we could not capture combinations of beverages drunk at each occasion. Lastly, we could not explore the effects of alcohol on cohabiting partnerships because that data were not collected at every wave.Panel studies like the RLMS are likely to suffer from selection bias because heavy drinkers and those with family problems are both less likely to take part and more likely to drop out . We tested this by adjusting the models for calendar time and formally tested for interactions, finding no evidence.This study adds to the literature by using longitudinal data, rather than cross-sectional. Although the temporal separation of drinking and divorce rules out reverse causality, we are not claiming that the results definitively demonstrate that alcohol causes divorce. The possibility remains of residual confounding by unmeasured factors, like conflict, mental illness, personality characteristics, parental divorce, union duration or relationship history. Further research could explore the potential pathways for how alcohol might lead to divorce, perhaps using methods such as structural equation modelling.This study finds that heavy and frequent drinking by either spouse increases the risk of subsequent divorce in Russia, and the association varies geographically and by aspects of alcohol use. This provides longitudinal evidence that alcohol is not just associated with individual harms, but with harm to family relationships. Given that Russia faces a serious alcohol problem, this finding supports the case for stricter control to prevent not only adverse health problems but also adverse social and family outcomes.At the time of the research, K.K. was funded by an Economic and Social Research Council PhD studentship. Funding to pay the Open Access publication charges for this article was provided by Research Councils UK (RCUK).Conflict of interest statement. None declared.


Increasing alcohol consumption among older individuals is a public health concern. Lay understandings of health risks and stigma around alcohol problems may explain why public health messages have not reduced rates of heavy drinking in this sector. A qualitative study aimed to elucidate older people's reasoning about drinking in later life and how this interacted with health concerns, in order to inform future, targeted, prevention in this group. In 2010 a diverse sample of older adults in North East England (ages 50–95) participated in interviews  and three focus groups . Data were analysed using grounded theory and discursive psychology methods. When talking about alcohol use older people oriented strongly towards opposed identities of normal or problematic drinker, defined by propriety rather than health considerations. Each of these identities could be applied in older people's accounts of either moderate or heavy drinking. Older adults portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However continued heavy drinking was also presented as normal behaviour for someone experiencing relative wellbeing in later life, or if ill health was construed as unrelated to alcohol consumption. Older people displayed scepticism about health advice on alcohol when avoiding stigmatised identity as a drinker. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were described. Identities offer a useful theoretical concept to explain the rises in heavy drinking among older populations, and can inform preventive approaches to tackle this. Interventions should engage and foster positive identities to sustain healthier drinking and encourage at the community level the identification of heavy drinking as neither healthy nor synonymous with dependence. Future research should test and assess such approaches. Trends towards increased consumption of alcohol even at levels well short of dependence raise concerns for public health, particularly among those in later life. Alcohol consumption and alcohol-related deaths or problems have recently increased among older age groups in many developed countries, including the USA, Australia and many countries of the European Union Risk of mortality over 20 years is increased among individuals aged 55–65 years consuming a daily average of 3 standard drinks  Heavy drinking is more widespread than physiological or psychological dependence on alcohol, and is often targeted by national policy, for instance through taxation, public health messages about its impacts and support for preventive non-specialist approaches such as brief interventions Rather than viewing health risks from alcohol as being outweighed by its desirability, older people may reason around alcohol primarily in social or moral rather than health terms These social theories have distinct implications for understanding why older people may be drinking more. We report a qualitative study in the UK, where substantial numbers of individuals over the age of 50 exceed governmental recommendations that adults (women/men) should not drink more than 3/4 units of 8 g of alcohol per day or 14/21 units per week This study was given favourable ethical approval by Newcastle University's Faculty of Medical Sciences Ethics Committee (application no. 000224/2009). In line with the terms of consent to which participants agreed, the data are not publicly available.In-depth interviews  were conducted between 19/11/09 and 15/03/10 by GW, a researcher with extensive experience of qualitative research on interventions for families or substance use. Purposive sampling aimed to recruit both genders and represent a broad range of age and self-reported drinking, past or current. Participants aged 50 and above were sought in order to consider views both leading up to and following the transition of retirement, and to consider how problems after the age of 65 may arise in late working life. Three local branches of a national charity aiming to improve later life (Age UK) and two regional services for alcohol problems were given research information leaflets. These explained the reasons and objectives for the research; what was involved in participation; how information would be handled and used; and who to contact for further information. The leaflets were distributed to service clients or volunteers who had experience of drinking alcohol at any level of consumption. Staff members invited the clients to consider participating in an interview, answered any questions they had about the research and asked those who were interested to complete and sign a consent form. GW contacted all potential participants by telephone to arrange a single interview; both on this call and prior to commencing interviews, the researcher checked that the individual was familiar with the research leaflet, answered any questions they had, reminded them of the voluntary and confidential nature of participation and checked that they were still happy to proceed. Initially 17 participants were recruited; although heavy drinkers were not particularly targeted in recruitment, most reported experience of dependence on alcohol. One further form was received but this participant withdrew consent without supplying a reason when contacted by GW. We sought the perspectives of older people with a range of patterns of consumption, in order to avoid over-representation of very heavy drinkers. For this reason a second wave of recruitment targeted only Age UK clients who drank but considered themselves to have had no problems with alcohol. Strategic ‘snowballing’, whereby interviewees suggested other individuals who could be invited to participate, added two further interviewees who were not using services. This increased the sample to 24, at which point the research team agreed that data saturation had been reached. Fifteen of these were recruited via Age UK, six of whom were also involved with voluntary services for mental health support. Considerable diversity was achieved see .Individual claims regarding stigmatised aspects of identity are likely to be qualified in the presence of peers, and recognising this influence is important to understanding how social contexts might also affect the implementation of preventive measures to address that behaviour. Focus groups with Age UK clients or volunteers were organised towards the end of data collection to allow comparison of individual accounts with socially negotiated versions of drinking in later life. Age UK staff, who also attended the groups, were asked to invite any men or women whose age made them eligible for Age UK services and who drank alcohol. One focus group was organised at each of three local branches; all those who expressed an interest attended one of these groups. The first group comprised 9 participants ; the second group comprised 12 participants  and the third comprised 6 participants . To encourage participation, focus group participants were not required to disclose personal details other than age, date of birth and address; these data were gathered on consent forms. The research team prepared topic guides (available on request) to initiate discussion or return talk to the research topics. At the groups, participants were invited by the facilitator (GW) to offer views in general rather than recounting personal experience in front of others. Interviews and focus groups lasted between 40 and 150 minutes either at individual respondent's homes or the offices of Age UK or other services, as well as one interview at Newcastle University.Interview and focus group data were audio recorded with consent, transcribed verbatim, anonymised and loaded into NVivo software. Analysis was informed by grounded theory and discursive psychology approaches. GW repeatedly read transcripts and coded for emergent themes; early analysis informed later interviews and focus groups In the individual interviews, two distinct and contrasting ways of presenting alcohol use in later life recurred consistently: one positive, one negative. In positive terms, alcohol was treated as something that could be enjoyed by older people who consumed it minimally or occasionally. Alcohol was drunk through choice, and therefore implied control over one's actions. Drinking offered benefits of sociability and relaxation: it kept older people from losing touch, and was associated with taking things easy. Finally, drinking alcohol could be portrayed as an integral and on-going element of community, working or family life. Some or all of these characteristics were used to account for consumption as something that maintained the quality of later life. For instance, in Excerpt 1 below, a woman describes her brother's drinking as positive even though he is ‘older than me’.Excerpt 1: … my brother and I both enjoy drink, both enjoy a social drink. My brother, even though he's a bit older than me, still has his lads' nights out where he has a damn good skinful, comes home after putting the world to rights and feels great, that can't be bad. The ‘skinful’ is presented as something taken with friends on occasions and through choice. It is part of a tradition connecting later life to earlier years and associated colleagues (‘still has his lads' nights out’) and has beneficial consequences (‘feels great’). By invoking these characteristics the speaker invites evaluation of this drinking behaviour as positive .At other times in the interviews, alcohol consumption by adults in general in later life was characterised as unacceptable or problematic. In negative terms, alcohol was used to cope with or ‘blot out’ difficulties in life. It was drunk excessively or frequently, and secretively or alone rather than in company. Consumption was driven by compulsion rather than choice and therefore implied a loss of self-control. Finally, drinking alcohol was presented as being in some way inconsistent with traditional behaviour or the way things were in earlier years. Some or all of these characteristics were invoked to present alcohol consumption in later life as negative. These sets of features, positive and negative, were always applied separately in interviews. Interviewees did not, for instance, report losing self-control on occasional nights out with former workmates; nor did they describe drinking simultaneously for enjoyment and to blot out difficulties. For example, in Excerpt 2, one man distinguishes his own drinking as positive formerly, when moderate, but negative in later years when dependent.Excerpt 2: I guess the social element of it, going down the pub having a few beers, [yeah] talking to the guys, game of darts, or maybe it was a party or something round at someone's place and New Year's Eve or a birthday party. And it was the social involvement, you just had a few beers and [uh uh] then eventually the few beers, it got to the stage where I couldn't have a few beers, once I had a beer I always had to have something else, I needed more and more and more. [yeah] And then it switched onto wine and spirits [liquor], I could never have one, I always had to have more. He emphasises that beforehand, his drinking was a controlled choice in that he stopped at ‘a few’; it was associated with special occasions and sociable activities with peers. As such, it is consistent with the picture of late life drinking offered by the speaker in Excerpt 1, and the behaviour is presented as normal here through the use of ‘you just had…’. A separate stage of problematic drinking, in contrast, involved an escalation to more and stronger alcohol than he had drunk previously in order to cope, and a compulsion to drink which he “could never” avoid (implying that he should have done so).Although positive and negative accounts of alcohol use were never combined, they were not always used to distinguish moderate from heavy drinking: it was observed elsewhere that positive characteristics could be applied to relatively heavy consumption, while moderate consumption could be portrayed in negative terms. For instance, one interviewee (17) indicated that she consumed a bottle of wine (9 units) a day; such consumption is well in excess of the recommended daily limit of 3 units for women. She went on to characterise her drinking in positive terms, as in Excerpt 3.Excerpt 3: …if somebody had found me in the corner drunk that would probably shock me into maybe stopping, but that's never happened. I would never drink to the excess where I didn't know what I was doing or anything, you know. It's only (.) I keep saying it's only 12% volume which isn't very high is it? Here, Interviewee 17 portrays her consumption as minimal on account of the percentage of alcohol in the wine she drinks, and therefore distinct from ‘excess’. She claims self-control, stressing that she always knows what she is doing and will not be found inebriated and helpless. By applying these positive characteristics to her drinking, she invites the interviewer to view her drinking as moderate, marked by her use of ‘only’. In the same way, alcohol consumption that would be considered low-risk in public health terms could be identified as negative by an interviewee; Excerpt 4 shows an example.Excerpt 4: Sometimes I've gone home from there and I haven't had a drink, but I've gone in and the first thing I've said to him was ‘I could just drink a glass of wine’ and he'll say ‘well why don't you?’ Well no. It makes me feel like I want to have a one, but it's never pushed me to want one. [yeah] You know, I have to have a drink because I'm relaxed and I want a one, not because I think I need a one. But sometimes I go home and I think ‘god, I could just have a glass of wine now’. You stop because I'm used to drinking in the olden days where they only drank on a Friday and Saturday. The woman speaking here presents alcohol consumption as something one has to stop because it might be undertaken from necessity rather than choice, and would be inconsistent with traditional times for drinking. To the extent that she does not suggest her companion will be drinking as well, it is portrayed as an individual rather than social undertaking. The consumption to which she refers - a glass of wine at home ‘sometimes’ - represents low-risk consumption according to recommended guidelines; however, her characterisation of it is consistent with the negative, unacceptable version of alcohol.To summarise, individual interviewees used different characteristics to label drinking in later life as either normal and thus positive, or else as unacceptable or problematic, and therefore negative. These positive and negative labels were not, however, clearly associated with distinct levels of moderate or excessive alcohol consumption.The same positive and negative features were also apparent in talk at focus groups. However, disparities between individual norms revealed the negotiation of social norms around alcohol. The flexibility in distinction between moderate and heavy drinking meant that identification of a pattern of drinking by one participant as either positive or negative could be challenged by another. ‘Alcoholics’ in general were often disparaged by the focus groups as people to be avoided or pitied, establishing the undesirability of being considered an alcoholic. Given this, negotiations took place to resolve what could be deemed positive or negative. Where claims of normality were challenged, the repertoires functioned to claim or ascribe particular identities as a positive or negative older drinker. Excerpt 5 shows an instance of this.Excerpt 5:F3: Well that's what we do if any of the family come down to visit. We go for a lunch. We go for a lunch and have like half a lager.F8: You don't need to drink do you?F3: You don't need to drink, but I might get one with my meal, you know. It's not a case of going out drinking. We're there for the company and the meal, so (.) that's what we do.F8: Well they didn't used to eat in pubs at all.(Focus Group 1)The consumption under discussion – half a pint of lager with an occasional meal – is low-risk according to UK guidelines. Participant F3 identifies this moderate drinking as normal (something ‘we do’) by presenting it as a choice within a sociable family context. That this represents an identity claim is demonstrated by participant F8's implication in response that F3 had ‘needed’ to visit a drinking venue rather than choosing to do so. By suggesting the drinking is driven by compulsion, she invites it to be seen in negative terms. Faced with this, F3 counters by restating the voluntary or occasional nature of her drinking (‘I might’) and asserting its essentially social function (‘there for the company’). F8 responds to suggest that F3's behaviour is not associated with tradition, again inviting a negative interpretation.In a similar way, one participant's claim for the normality of heavy drinking could be challenged; Excerpt 6 shows an example of this.Excerpt 6:M3: I was away last week, and one particular gadgy [man], he supped 10 pints and he was immune to it, you know. I mean//F4://Was he rational in everything, and could he walk?M3: Well aye, you wouldn't think he'd been out.F4: Had he got his senses? (.)M3: He's done it all his life.F4: Had he got his senses?M3: He seemed to be alright to me like. Or not me [laughs], I had about 8, but you know this gadgy he'd done it all his life, and nowadays, it's now the young ones that get 10, they'll go and put shop windows in, because they can't take it.Participant M3 presents the drinking of 10 pints by a drinking companion in one session as controlled and occasional. F4, however, questions whether the drinker in question could have been ‘immune’ to the effects of this consumption (considerably in excess of recommended daily guidelines) and implies loss of self-control of this person's reason and ability to walk. M3 rebuts this, but faced with a repeated challenge he resists the insinuation of negative drinking by asserting that his drinking companion had life experience within which this was normal. This is finally reinforced by aligning his own drinking with that of his companion and treating this as humorous, then suggesting that only younger people without their experience are likely to lose self-control after such consumption.Exchanges such as these show that not only are definitions of moderate and heavy drinking flexible, they are contested among older adults in establishing the parameters of acceptable behaviour. To the extent that self-control and adherence to traditional practices were treated as key characteristics of normal drinking, propriety emerged as central for participants in evaluating levels of alcohol consumption.Individual interviewees did not refer spontaneously to health when discussing alcohol consumption; however, the researcher specifically asked about health as a topic of research interest in the individual interview schedule. Analysis explored how participants treated their health as a factor when accounting for choosing either to drink less, or not to do so.In the individual interviews, some interviewees reported a decision to reduce or abstain from alcohol consumption. They referred to a range of chronic conditions, and the use of medicines prescribed for these, in relation to these decisions. Narratives of a major injury or health scare, such as hospitalisation for pancreatitis or pneumonia were commonly concluded with a decision to cut down. Some conditions or events such as falls were explicitly attributed to drinking, typically where the speaker recognised an impact of alcohol on their symptoms; the experience of symptoms getting worse with drinking could be offered to rationalise the need to cut down. For instance, the speaker in Excerpt 7 attributes his tendency to fall at least partly to drinking.Excerpt 7: I still haven't packed in smoking, but I've packed in drinking because of the balance. As you know, if I have too much to drink I just go backwards. This was particularly, but not solely, the case with those who identified themselves as formerly dependent on alcohol. The experience of side-effects from drinking while on medication could also be used to explain cutting down, for instance by a woman on medication for bipolar disorder who described ‘terrible hangovers’ when she had also drunk alcohol. Those saying they had reduced drinking for health reasons pointed to resulting improvements in their symptoms.Other interviewees described continuing to drink heavily despite experiencing impaired health. This could be accounted for as self-medication to relieve symptoms, as in Excerpt 8.Excerpt 8: The pain. Even some of my bones with my osteoporosis. My ankles, my everything. The pain and all that. As soon as I start having a few pints it goes away. Where interviewees identified themselves as dependent, some explained that they were unable or that it was ‘too late’ to change their drinking regardless of whether it had an impact on other health conditions. In particular, they described a cycle of mental health and alcohol problems that kept them using alcohol: drinking exacerbated their conditions in its aftermath, but going without alcohol meant facing a return of feelings or symptoms, as in Excerpt 9.Excerpt 9: I've told the doctor there's no way I'll stop drinking. There's no way I can stop drinking. There's too much up there, and it's too late. Too much in my head. Elsewhere in the interviews, health conditions in later life were described as unrelated to heavy drinking, either because overall health and wellbeing was relatively good for their age and symptoms were not experienced, or because symptoms were perceived as being unaffected by drinking. For instance, in Excerpt 10, a man who had suffered a stroke discounts health professionals' advice to reduce consumption since he feels in relatively robust health.Excerpt 10: I'm 55, I'm perfectly fit, I don't run about beating everyone up, I'm not incontinent, I'm perfectly healthy, I get a check for my stroke, which coincidentally, they check my bloods, they check my liver, check my pancreas, check my kidneys you know, everything's fine, so how is this half a dozen pints doing any irreparable damage? Interviewees who described drinking while taking prescribed medication also said they judged any threat to their health from this according to whether they felt ‘fine’. Health risks were also discounted on various grounds that medications would be ‘in my system’ before alcohol mixed with them (as in Excerpt 11) or would not have been prescribed if unsafe to take with alcohol.Excerpt 11: I still take them [tablets] anyway and I've been taking them regular. It hasn't done nowt [nothing] wrong to me but numbing my brain a bit. That's all I can see what's happening. If that was the case I would just leave the tablet alone and just stop on the beer (.) I take them on a morning anyhow, and they're probably in my system by the time I have drink and stuff like that. Choosing to drink heavily while suffering health conditions could be perceived as irrational. When reporting this behaviour, interviewees' talk anticipated this: for instance, Excerpts 10 and 11 are framed to question or refute such a perception . Links between alcohol intake and poor health were also more explicitly challenged; some participants described themselves as having disproved doctors' warnings about alcohol affecting their health. UK government guidelines for low-risk drinking were usually referred to sceptically for being unrealistic or failing to take account of individual capacities; Excerpt 12 gives an example of this.Excerpt 12: Now, I'm older, my body is bigger than yours so I could obviously take more drink than you. So people aren't stupid, they know that people take drink in different ways. So making it just a huge umbrella and saying ‘you drink 4 units and you'll be alright’, it doesn't make sense. Like individual interviewees, focus group participants did not refer spontaneously to health when discussing alcohol consumption. In response to questions about health, it was again suggested that experiencing a physical impact from health conditions or impairments warranted reduced alcohol use as part of a generally healthier lifestyle. For instance, in Excerpt 13, a participant asserted that drinking less was consistent with being a cancer survivor, without attributing that illness to alcohol use per se.Excerpt 13:F2 …I've had a serious cancer operation which you all know, but I don't drink; I have a drink, I drink, not a lot of [it]; I have a couple of lagers or something: finished. I don't go over the top, but that's individual. You know that you've been, you've been very ill and this sort of thing and it's no good pushing it down your neck, because you're only making yourself worse…Continuing to drink heavily while suffering a health condition or taking medication, however, was only attributed to ‘other’ older people rather than those present. In this respect, there appeared to be tacit recognition that heavy drinking with a chronic condition should be seen as a health concern. However at points in two of the groups, participants reached a consensus regarding scepticism about medical advice provided on alcohol. It could be agreed, for instance, that health professionals were overly ready to attribute older people's health problems to their alcohol intake, as in Excerpt 14.Excerpt 14:F3: Even, even if you go to an asthma clinic they ask you if you drink and how many units in a week.F5: And really what has it got to do with anything?(Focus Group 3)Another basis for agreement was a belief that evidence on health risks from alcohol was contradictory or changeable and therefore inconclusive; Excerpt 15 gives an example of this.Excerpt 15:F1: I don't think that anybody has the authority//F2://No, I don't think they have got the right//F1://or should in any way, shape or form stop anybody from drinking if they want to.F4: Because it's bad for your health.F2: But everything is bad for your health.F1: Exactly.F2: I mean eggs, you cannot have eggs, or you couldn't.F1: Well, every other day there's something they tell you is bad for you.(Focus Group 3)In this exchange, participants agree that people should not be prevented from drinking on health grounds because too many products or behaviours have, or could be, found to carry health risks. Medical practitioners' encouragement of reduced drinking can be branded unreasonable if driven by health warnings from research that are excessive: if ‘everything is bad for you’, then it is irrational to assume that health risks can be avoided. The example of revised warnings against eating eggs is cited to emphasise that such public health messages can be regarded as provisional pending future studies.Individual interviewees rarely made links between gender and drinking behaviour. However, some subtle distinctions were made by participants regarding culturally appropriate drinking practices among men and women in this setting. For example, men's heavy consumption of beer with groups of other men in pubs was valorised, as in Excerpt 16, while women drinking beer or going to pubs, particularly if alone, would be viewed negatively, as in Excerpt 17:Excerpt 16: …now I've sat with them and I've drunk with them. If they drink 15 pints a night or drink until they fall down, that makes them a man. Excerpt 17:Interviewee: But since he [husband] died 18 years ago I've never been in a pub sinceGW: No? Why did you stop going?Interviewee: Well when you're on your own you don't. However, such attitudes or behaviours were often presented as a feature of past behaviour. Some participants who had experienced alcohol dependence described drinking in a way that challenged traditionally gendered patterns: for instance, a man who had tended to drink sweet wine at home, or women who described drinking beer in pubs or with male friends. Rather than separately gendered patterns of consumption, couples drinking together emerged as a characteristic of retirement compared with earlier life. There were however some indications that men could regret this shift away from earlier drinking with peers, as in Excerpt 18.Excerpt 18: …one or two of them [lads], because they're 50 odd years, the same age, they're taking more the role of the husband taking the wife out. I take the wife out, but the Friday night, I think, is sacrosanct. But now it's getting less and less so. Focus group accounts were also almost always voiced in terms of ‘older people’ or people in general. The few gender-specific aspects of drinking brought up were usually references to men or women typically drinking together in groups on a regular ‘lads’ or ‘girls’ session, as in Excerpt 19.Excerpt 19:F4: my husband and a lot of the lads up here work with the shipyards; they all meet in one of the clubs over the water on a Saturday afternoon, and there's still about 15 of them all get over there, and they have a drink.(Focus group 2)For men, this meant drinking together in pubs, typically after work to ‘get in amongst the fellas’ as one participant put it. Such drinking was emphasised at the groups as positive, intended for socialising and not getting drunk. This is in contrast with individual interviewees in Excerpts 2 and 16 above, who depicted heavy drinking with ‘the lads’ in pubs as a precursor to their dependence on alcohol. At the all-female focus group, participants anticipated that men should drink beer in pints, with one participant in Excerpt 20 finding it ‘unmanly’ for her partner to drink otherwise:Excerpt 20:F5: Sometimes I could clip [partner's name] because he'll always get a half pint and I want him to have a pint. [laughs]F4: Good for himF5: Because I don't think it looks macho with this stupid little half pint.(Focus Group 3)Female participants in the focus groups also identified that women drinking in pubs could be seen in negative terms. However, any differences in how men and women drank were typically proposed in relation to an earlier stage in life or days gone by, with the speaker or another participant suggesting that this was no longer the case, as in Excerpt 21.Excerpt 21:F2: I think a lot of the men go out a lot more. The older men do still drink. Because that's their only entertainment really, isn't it? I would say middle aged men -F5: I don't think it's just men. I think ladies can drink just as much as men.F2: I'm talking about going out for a drink though, you know. Do you think the older ladies do?F5: Oh yeah, I would say so(Focus Group 2)Whilst specific references to gender were infrequent, the fact that they were evident at all suggests that older adults recognised gender-based patterns of drinking and also issues of stigma in relation to public drinking by women and deviations from male drinking stereotypes, which could challenge attempts to reduce consumption, such as drinking smaller quantities of alcohol.The aim of this research was to contribute to contemporary understandings of alcohol use in later life and its implications for the health of older people. UK adults in later life who were asked to talk about alcohol and health oriented strongly towards the opposed identities of normal or problematic drinker, the latter being highly stigmatised. These identities were defined primarily by self-control and propriety, rather than health considerations. In data from focus groups, participants could be seen to negotiate consensual views on alcohol and its implications for both health and propriety, providing support for their views being socially constructed in response to a particular context. These older people portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However, continued heavy drinking could be presented as normal behaviour for someone experiencing relative wellbeing in later life, or if their experience of ill health was construed as unrelated to alcohol consumption. This normalisation was supported by treating general health advice on alcohol as questionable or individually irrelevant. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were evident.Absolute numbers of risky drinkers in older age groups are small compared with younger adults but will grow in an ageing population The scepticism displayed by participants towards health advice regarding alcohol consumption is consistent with resistance to health promotion reported for other lifestyle issues, such as smoking Increasing alcohol consumption among older age groups might instead reflect identity work in this population. Older adults can be relatively ill-informed about alcohol measurements on which guidelines are based Drinking behaviour did not appear to be strongly defined by gender in our study in contrast to other qualitative work. This difference may reflect the fact that gender-based issues were not the main focus of this study. Some gendered expectations of drinking were described, often with a focus on culturally stereotyped patterns of consumption. In line with findings from somewhat younger UK men Longitudinal studies of large samples of older adults in both the US and Norway have shown reduced drinking linked to the incidence of chronic or painful medical conditions Although the overuse of alcohol in later life and its associated stigmas are clearly concerns for public health Consideration of our data in light of theories of lay epidemiology and identities has informed an under-recognised area of public health concern. Strengthening the evidence for specific risks to health from alcohol and clarifying how these interact with behaviour might increase the impact of preventive strategies to reduce heavy drinking in later life. However, the processes by which identities can be constructed are ‘tremendously powerful’ in governing social interaction , p5, and


In-person structured observation is considered the best approach for measuring hand hygiene behavior, yet is expensive, time consuming, and may alter behavior. Video surveillance could be a useful tool for objectively monitoring hand hygiene behavior if validated against current methods.Student hand cleaning behavior was monitored with video surveillance and in-person structured observation, both simultaneously and separately, at four primary schools in urban Kenya over a study period of 8 weeks.Video surveillance and in-person observation captured similar rates of hand cleaning . Video surveillance documented higher hand cleaning rates (71%) when at least one other person was present at the hand cleaning station, compared to when a student was alone . Students increased hand cleaning rates during simultaneous video and in-person monitoring as compared to single-method monitoring, suggesting reactivity to each method of monitoring. This trend was documented at schools receiving a handwashing with soap intervention, but not at schools receiving a sanitizer intervention.Video surveillance of hand hygiene behavior yields results comparable to in-person observation among schools in a resource-constrained setting. Video surveillance also has certain advantages over in-person observation, including rapid data processing and the capability to capture new behavioral insights. Peer influence can significantly improve student hand cleaning behavior and, when possible, should be exploited in the design and implementation of school hand hygiene programs. Measurement of hand hygiene behavior is important for evaluating program effectiveness, as well as for understanding the relationship between hygiene and health. Few methods exist, however, to measure hand hygiene behavior reliably, accurately, and efficiently Some studies have used video surveillance to capture hand hygiene behavior in high-income countries. Video cameras were used to capture hand hygiene behavior in hospitals in the United States, Japan, and China as early as the 1990s versus rates captured by each method independently. In addition, by comparing rates of hand cleaning when students are alone versus in the presence of others, we assess peer influences on hand hygiene behavior. Finally, the benefits and drawbacks of using cameras to measure hand hygiene behavior are discussed.The main objective of this analysis was to evaluate the viability of using video cameras to measure hand-cleaning behavior accurately within a low-income school setting. At primary schools in Kenya, video cameras recorded footage of hand cleaning stations located next to latrines. We compare data on hand cleaning rates after toileting events captured by video camera with data collected through in-person structured observation to assess concordance between the two methods. We also explore student reactivity to video surveillance and in-person observation by assessing rates of hand cleaning during simultaneous monitoring This study was conducted in four primary schools located within the informal settlement of Kibera, located in Nairobi, Kenya. Data collection occurred between September and November 2010. The four schools were participating in a school-based hand hygiene evaluation of alcohol-based hand sanitizer compared to traditional soap; schools were selected based on similar student populations, water supply, and sanitation characteristics. The full hand hygiene study design is described elsewhereVideo cameras were positioned such that the camera surveillance frames included the doors to the latrines as well as the hand cleaning station . The camP,I, V,I), and simultaneous in-person observation and video surveillance . In addition, on days with simultaneous monitoring, video cameras recorded from 9:30am–10:30am, the hour preceding the start of in-person observation.A rotating field schedule was employed to capture toileting events simultaneously and separately by video surveillance and in-person observation . During To assess teacher awareness of student reactivity to observation, in-depth interviews were conducted with 3 teachers per school (N = 12). These semi-structured interviews included open-ended questions about whether and how the CCTVs and in-person observation affected hand hygiene behavior at the school. The interviews were voice recorded, transcribed, and then translated into English.In-person observation and video surveillance coding were generated with the use of personal digital assistants (PDAs) loaded with a survey instrument programmed in The Survey System . Trained observers sat within view of the latrines during in-person observation and coded toileting events in real time using PDAs. Observers did not initiate interaction with students or teachers during data collection. Video footage was coded by 4 research assistants at Stanford University. Surveillance footage without students in the camera frame was viewed at increased speed using the fast-forward feature in media viewing software. When a student subject appeared in the frame, the footage was typically observed in real time, paused if necessary, and rewound to capture details if needed. Qualitative notes were also recorded to document relevant details and behaviors not captured by the survey instrument on the PDA.For both in-person observation and video surveillance, each student exit from a latrine was considered a “toileting event.” When multiple students cleaned their hands simultaneously, both in-person and video coders were instructed to select one student arbitrarily to follow. Observers recorded if a student cleaned his or her hands with water, soap, and/or sanitizer following each toileting event. Observers also documented the student's gender (by the school uniform), the duration of hand cleaning in seconds, and the method of drying hands. Video coders also collected data on the number of other students visible within the camera frame.In-person observation and video footage data for each school were compared in aggregate across all observations. The difference in rates captured by the two methods (rate ratios) of any type of hand cleaning and hand cleaning with product were estimated using Poisson regression, including binary variables to identify the individual school at which the data were collected (school fixed effects). The modeling results were also stratified by intervention type. In-person observation and video footage data were then matched by concurrent 3-hour time blocks. A date and time stamp of each toileting event was recorded automatically by the PDA during in-person observations, and by the camera itself for the video recordings. To compare in-person structured observation with video observation on the same day, video data were coded as occurring on a day without in-person observation or on a day with in-person observation. The number of toileting and hand cleaning events was summed within each of these periods, then merged to obtain a complete data set for each school day. For these simultaneous observation periods, independent sample t-tests were used to assess significant differences in overall hand cleaning rates, hand cleaning rates with soap, and the number of toileting events captured by each method.To explore reactivity to video surveillance, hand cleaning rates captured by in-person observation were compared between days with and without concurrent video camera surveillance. A similar analysis was conducted with video surveillance data to estimate reactivity to structured observation. Rate ratios (between independent and simultaneous monitoring) were calculated using Poisson regression, controlling for the individual school the data were collected from. Modeling results were also stratified by intervention type to examine any differences in reactivity between sanitizer and soap intervention schools. In addition, on days with simultaneous monitoring, hand cleaning rates captured by video surveillance in the hour preceding in-person observation were compared to rates captured once in-person observation had begun.Administrators from the study schools gave written consent for video cameras to be placed in public locations on the school premises. Written consent to observation was also obtained from teachers and the parents of enrolled students. Video surveillance was not specifically mentioned in parental consents for the following reasons: a) identities of individuals could not be recognized in the video surveillance due to limited resolution of the footage; b) the cameras were placed in public locations; and c) there was concern that explicitly publicizing video surveillance to parents could amplify student reactivity to the surveillance. It should be noted that both video surveillance and in-person observation captured non-target behaviors at times, such as students fighting or urinating/defecating outside the latrines. Teachers and school administrators were informed that the cameras could not be used to monitor illicit behavior since students were not identifiable in the footage. Ethical approval for the project and all consent procedures described above (including not informing parents of video surveillance) was obtained from the Stanford University Institutional Review Board (PR#: 19143) and the Kenya Medical Research Institute (KEMRI) Scientific and Ethical Research Committees (No. 1840).A total of 5,510 student toileting events were captured by in-person observation during 46 unique school-days at sanitizer intervention schools and 51 unique school-days at soap and water intervention schools. Video surveillance captured 2760 toileting events over 21 school-days at sanitizer schools and 20 school-days at soap and water schools. Overall, hand cleaning rates  captured by video observation were higher (64%) than hand cleaning rates documented during in-person observation (56%); however, the rates were not significantly different when controlling for the individual school at which the data were collected . Trends Both methods found that female students cleaned their hands slightly more often than boys; the hand cleaning rate after toileting was 4% higher among girls according to video surveillance (p = 0.02) and 3% higher according to in-person observation (p = 0.01). Average hand cleaning time recorded during video observation was significantly higher  than that recorded during in-person observation . Both video observation and in-person observation demonstrated longer hand cleaning times for handwashing with soap than rubbing with sanitizer .versus video observation was not significant . Similar results were obtained for comparisons of hand cleaning rates with soap  and with sanitizer . However, the mean number of toileting events captured by in-person observation over a 3-hour period was significantly higher than that captured by video observation .In-person observation and video surveillance data were directly matched and compared for 22 school-days, each with 3-hours of observation overlap . The absolute difference in mean hand cleaning rates captured by in-person observation Overall, in-person observation data collected with and without concurrent video surveillance show significantly higher hand cleaning rates during video surveillance periods . Overall, when students were alone at a hand cleaning station, hand cleaning rates averaged 48%, compared to 71% when at least one other student was present . At sanie.g. lifting young students up to reach wall dispenser, placing product on hands); 3) Students reminding other students to clean hands and/or demonstrating proper technique; 4) Groups of students engaged in conflict over access to hand cleaning materials ; 5) Students being called away from hand cleaning stations by teachers to attend class.Video coders noted the following scenarios when more than one person was present at the hand cleaning station: 1) Teachers instructing groups of students on proper hand cleaning technique; 2) Older students assisting younger students  for each method was outside the scope of this study, and would be a valuable area for future research.We found evidence of student reactivity to both video surveillance and in-person observation, in the form of higher hand cleaning rates at handwashing with soap intervention schools. Reactivity was not detected at sanitizer intervention schools; this may be explained by the fact that hand cleaning rates with sanitizer were over 80%, leaving less room for compliance rates to shift upwards. Reactivity to simultaneous video and in-person observation increased handwashing rates by similar magnitudes . These data should be interpreted as the marginal impact of each observation method on behavior when the other method is also in effect, as reactivity to each method could be higher when compared to a period during which no observation is occurring. Reactivity measured in this study was less than the 35% increase in hand cleaning frequency due to structured observation found by Ram and colleagues (2010) among female caregivers of young children The presence of at least one other person at the hand cleaning station increased student hand cleaning rates by 14% among all schools, indicating that peer influence can significantly impact student hand cleaning compliance. Reaction to peer presence has previously been documented to increase hand hygiene compliance among adults. A previous study found that female students cleaned their hands 91% of the time after using the bathroom when someone else was present, compared to 55% of the time when they were alone in the sink area The positive influence of peer presence on student hand hygiene behavior observed in this study has key implications for the design and implementation of future hand hygiene programs in schools. Placement of hand cleaning materials in public locations, along with the scheduling of specific times for bathroom breaks between classes, could significantly improve student hand hygiene compliance rates. Strategies to instill hand hygiene as a social norm may also be effective, such as designating specific students to be hand hygiene “champions,” or the formation of student clubs to demonstrate and promote hand hygiene to their classmates Some disadvantages to using video surveillance were evident. Cameras had to be padlocked during the day and removed nightly to avoid theft and vandalism. Minimal available space and flimsy school walls made installation and stable positioning of the camera difficult. On some occasions, cameras were knocked or fell into positions that did not capture the full view of the latrine entrance and hand cleaning station. Notably, it was infeasible to utilize cameras to record hand cleaning at control schools in this study, because one school did not keep its hand cleaning materials (i.e. portable basin and soap) in a specific place. Video surveillance is thus best suited for monitoring compliance at fixed hand cleaning stations.We found that video surveillance has several potential advantages as an observational method. First, video surveillance significantly reduced the amount of local staff time necessary for data collection. The cameras had motion sensors to trigger recording only when movement was detected at hand cleaning stations, thus eliminating staff time spent observing the hand cleaning station when latrines were not in use. Moreover, video footage could be analyzed at increased speeds. Video surveillance also allowed off-site research staff to view intervention compliance directly, to replay footage to capture additional information, and to witness unexpected reasons for non-compliance. Video surveillance is a useful method for monitoring hand hygiene behavior that enables rapid synthesis of rich behavioral data.