Associate Professor Penny Buykx

Background: This paper considers the extent to which people drinking at harmful levels responded to minimum unit pricing (MUP) in Scotland in the way they, family members and those providing services anticipated they would. It examines data taken from a larger evaluation of the impact of MUP on people who are drinking at harmful levels. Methods: Qualitative interview data, (utilizing interviews and focus groups, with individuals, treatment services, and family members) was generated prior to the implementation of MUP in Scotland to provide insights into anticipated responses and comparable data generated across an extended 19-month period post-implementation and provided insights into actual responses. Results: Overall, the data showed consistency between anticipated and actual responses, with fewer differences observed. In line with anticipated responses, many drinkers switched from cheap, strong ciders to other alcohol products, notably vodka. They consistently responded to the decrease in alcohol affordability by utilizing existing behavior such as managing finances and prioritizing spends on alcohol, including borrowing money, foregoing essentials, and using savings. There was less evidence of anticipated harmful consequences of MUP occurring, such as increased crime, switching to other drugs, or examples of acute withdrawal. Conclusions: Drinkers and those living and working with them, have a good command of how alcohol affordability is maintained or impacts on expenditure and other choices, and how they respond to any decrease in affordability including the introduction of minimum price policies.

Background: Alcohol and tobacco have different policy regimes and there is little understanding of how changes to policy on each commodity might combine to affect the same outcomes or to affect people who both drink and smoke. The aim of this study was to deepen understanding of the policy objectives of UK alcohol and tobacco tax options being considered at the time of the interviews with a set of UK policy participants in 2018, and the factors affecting the implementation and outcomes of the policy options discussed. Methods: Ten tax policy experts were recruited from government arms-length organisations and advocacy groups in England and Scotland (4 alcohol, 4 tobacco, 2 alcohol and tobacco). Alcohol and tobacco experts were interviewed together in pairs and asked to discuss alcohol and tobacco tax policy objectives, options, and the mechanisms of effect. Interviews were semi-structured, supported by a briefing document and topic guide, audio-recorded, transcribed and then analysed deductively using framework analysis. Results: Alcohol and tobacco tax policy share objectives of health improvement and there is a common set of policy options: increasing duty rates, duty escalators, multi-rate tax structures, industry levies and the hypothecation of tax revenue for investment in societal benefits. However, participants agreed that the harms caused by alcohol and tobacco and their industries are viewed differently, and that this influences the impacts that are prioritised in tax policymaking. Working-out how alcohol and tobacco taxes could work synergistically to reduce health inequalities was seen as desirable. Participants also highlighted the importance of avoiding the combined effects of price increases on alcohol and tobacco widening economic inequalities. Conclusions: Impact analyses should consider the combined effects of alcohol and tobacco tax policies on health and economic inequalities, and how the effects of changes to the tax on each commodity might trade-off.

OBJECTIVES: Alcohol contributes to significant health, social and economic burdens worldwide, but evidence-based policy options can reduce the harm associated with alcohol use. The aim of this paper is to understand factors influencing public support for various alcohol policies in New South Wales (NSW), Australia, and to determine any change over time. METHODS: An online survey of adults in NSW, in 2013 (n = 2482), 2016 (n = 1585) and 2019 (n = 1601), assessed support for alcohol policies. Multivariable logistic regression models examined the change in support over time, adjusting for demographics, alcohol consumption, smoking status and knowledge of alcohol as a risk factor for cancer. RESULTS: Most participants (68-72%) supported policies preventing underage internet users from exposure to alcohol advertising, and banning alcohol sponsorship of underage music and sporting events. Fiscal policies and restrictions on the number of alcohol outlets were the least supported policies (<40% support). Compared with 2013, participants in 2016 and 2019 were less likely to support policies increasing price, applying a volumetric tax and reducing the number of alcohol outlets. In 2019, more than 55% of respondents were aware that alcohol was a cancer risk factor, and knowledge of that relationship was associated with an increased likelihood of support for alcohol policies. CONCLUSIONS: Support was greatest for alcohol harm-reduction policies that had less impact on an individual's drinking. Overall, support for alcohol policies in NSW is not increasing. Initiatives to raise awareness about the health consequences of alcohol use, together with effective alcohol policies, are needed to counter industry influence on decision makers and negative public discourse.

Purpose: This paper aims to illustrate the complexity of understanding and managing violent behaviour in health care. The authors will show how different perceptions of the reasons for violent behaviour, and linkages between violent behaviour and illness have contributed to the creation of a wicked problem and added significant complexity to the management of violence towards staff within health-care settings. This paper will conclude with a call for strong multi-disciplinary action to address this ongoing issue. Design/methodology/approach: A narrative review was undertaken to explore the ways that violence has been perceived in health care and the ways in which the concept of violence has moved from being seen as a criminal issue to being within the realms of disease. This paper will show the importance of understanding who is perpetrating violence in health care, why and in what settings. It will expound on the idea that considering violence as a consequence of disease necessarily adds a layer of complexity to both individual and organisational responses to violence towards health-care staff. Findings: Understanding the complexity in preventing and managing violence against health-care staff can assist policymakers and managers to develop multi-faceted approaches to violence prevention, including better recognition and understanding of perpetrators of violence. Originality/value: This paper provides a unique perspective on thinking about violence in health care and the implications of its complexity.

Introduction: The UK low-risk drinking guidelines were revised in 2016. Drinkers were primarily informed about the guidelines via news media, but little is known about this coverage. This study investigated the scale and content of print and online textual news media coverage of drinking guidelines in England from February 2014 to October 2017. Methods: We searched the Nexis database and two leading broadcasters' websites (BBC and Sky) for articles mentioning the guidelines. We randomly selected 500 articles to code for reporting date, accuracy, tone, context and purpose of mentioning the guidelines, and among these, thematically analysed 200 randomly selected articles. Results: Articles mentioned the guidelines regularly. Reporting peaked when the guidelines revision was announced (7.4% of articles). The most common type of mention was within health- or alcohol-related articles and neutral in tone (70.8%). The second most common was in articles discussing the guidelines' strengths and weaknesses, which were typically negative (14.8%). Critics discredited the guidelines' scientific basis by highlighting conflicting evidence and arguing that guideline developers acted politically. They also questioned the ethics of limiting personal autonomy to improve public health. Criticisms were partially facilitated by announcing the guidelines alongside a ¿no safe level of drinking¿ message, and wider discourse misrepresenting the guidelines as rules, and highlighting apparent inconsistencies with standalone scientific papers and international guidelines. Discussion and Conclusions: News media generally covered drinking guidelines in a neutral and accurate manner, but in-depth coverage was often negative and sought to discredit the guidelines using scientific and ethical arguments.

Objective: The Northern Territory (NT) Government introduced a minimum unit price (MUP) of $1.30 per standard drink (10g pure alcohol) explicitly aimed at reducing the consumption of cheap wine products from October 2018. We aimed to assess the impact of the NT MUP on estimates of beverage-specific population-adjusted alcohol consumption using wholesale alcohol supply data. Methods: Interrupted time series analyses were conducted to examine MUP effects on trends in estimated per capita alcohol consumption (PCAC) for cask wine, total wine and total alcohol, across the NT and in the Darwin/Palmerston region. Results: Significant step decreases were found for cask wine and total wine PCAC in Darwin/Palmerston and across the Northern Territory. PCAC of cask wine decreased by 50.6% in the NT, and by 48.8% in Darwin/Palmerston compared to the prior year. PCAC for other beverages (e.g. beer) were largely unaffected by MUP. Overall, PCAC across the Territory declined, but not in Darwin/Palmerston. Conclusion: With minimal implementation costs, the Northern Territory Government's MUP policy successfully targeted and reduced cask wine and total wine consumption. Cask wine, in particular, almost halved in Darwin/Palmerston where the impact of the MUP was able to be determined and considering other interventions. Implications for public health: Implementation of a minimum unit price for retail alcohol sales is a cost-effective way to reduce the consumption of high alcohol content and high-risk products, such as cheap cask wine.

It is estimated that over 100 million people worldwide are affected by the substance use of a close relative and often experience related adverse health and social outcomes. There is a growing body of literature evaluating psychosocial interventions intended to reduce these adverse outcomes. We searched the international literature, using rigorous systematic methods to search and review the evidence for effective interventions to improve the wellbeing of family members affected by the substance use of an adult relative. We synthesised the evidence narratively by intervention type, in line with the systematic search and review approach. Sixty-five papers (from 58 unique trials) meeting our inclusion criteria were identified. Behavioural interventions delivered conjointly with the substance user and the affected family members were found to be effective in improving the social wellbeing of family members (reducing intimate partner violence, enhancing relationship satisfaction and stability and family functioning). Affected adult family members may derive psychological benefit from an adjacent individually focused therapeutic intervention component. No interventions fully addressed the complex multidimensional adversities experienced by many families affected by substance use. Further research is needed to determine the effect of a multi-component psychosocial intervention, which seeks to support both the substance user and the affected family member.

Alcohol consumption may play an important part in intimate heterosexual relationships, including regulating partners' emotional well-being and sustaining relational bonds. Quantitative studies consistently indicate that women play a prominent role in the informal surveillance of their partners' drinking. This paper aims to contribute to the evidence-base by examining possible meanings and reasons underpinning the surveillance of drinking in the early parenting period. In doing so, we draw from the results of a study conducted in Yorkshire (UK), exploring accounts of alcohol drinking practices in women up to three years after giving birth. This is a phase of family readjustment, in which childcare is at its most time- and labour-intensive. Free Association Narrative Interviews (FANI) were conducted between 2017 and 2018 with 21 working mothers from different backgrounds, each interviewed twice about daily routines and drinking practices. Narrative and thematic content analysis cast light on the gendered aspects of surveillance of alcohol consumption. Participants described seeking to exert informal surveillance over their partners' drinking and to set boundaries around what was considered an acceptable level of consumption. Their accounts reflected how traditional gender performances and expectations were relationally constructed through drinking practices. Women's attempts at surveillance were generally articulated in non-confrontational language. However, in the interviews, women expressed disappointment and unhappiness that partners' drinking activities were associated with an unequal distribution of domestic responsibilities. Through informal surveillance of drinking, we argue, women performed actions of health-risk management within the family. Most importantly, informal surveillance appeared to be a strategy which sought to negotiate a fairer allocation of household labour, and greater equity between the partners. Findings demonstrates how inequalities in power play out and permeate intimate relationships, re-affirming women's traditional role in the regulation of drinking. Drinking practices, we conclude, provide valuable insights into how gender operates in the sphere of intimacy.

Mothers¿ alcohol consumption has often been portrayed as problematic: firstly, because of the effects of alcohol on the foetus, and secondly, because of the association between motherhood and morality. Refracted through the disciplinary lens of public health, mothers¿ alcohol consumption has been the target of numerous messages and discourses designed to monitor and regulate women's bodies and reproductive health. This study explores how mothers negotiated this dilemmatic terrain, drawing on accounts of drinking practices of women in paid work in the early parenting period living in Northern England in 2017¿2018. Almost all of the participants reported alcohol abstention during pregnancy and the postpartum period and referred to low-risk drinking practices. A feature of their accounts was appearing knowledgeable and familiar with public health messages, with participants often deploying ¿othering¿, and linguistic expressions seen in public health advice. Here, we conceptualise these as Assumed Shared Alcohol Narratives (ASANs). ASANs, we argue, allowed participants to present themselves as morally legitimate parents and drinkers, with a strong awareness of risk discourses which protected the self from potential attacks of irresponsible behaviour. As such, these narratives can be viewed as neoliberal narratives, contributing to the shaping of highly responsible and self-regulating subjectivities.

Background and aims: Recent years have seen a rise in new and innovative policies to reduce alcohol consumption and related harm in England, which can be implemented by local, as opposed to national, policy-makers. The aim of this paper is to explore the processes that underpin the adoption of these alcohol policies within local authorities. In particular, it aims to assess whether the concept of policy transfer (i.e. a process through which knowledge about policies in one place is used in the development of policies in another time or place) provides a useful model for understanding local alcohol policy-making. Methods: Qualitative data generated through in-depth interviews and focus groups from five case study sites across England were used to explore stakeholder experiences of alcohol policy transfer between local authorities. The purposive sample of policy actors included representatives from the police, trading standards, public health, licensing, and commissioning. Thematic analysis was used inductively to identify key features in the data. Results: Themes from the policy transfer literature identified in the data were: policy copying, emulating, hybridization, and inspiration. Participants described a multitude of ways in which learning was shared between places, ranging from formal academic evaluation to opportunistic conversations in informal settings. Participants also described facilitators and constraints to policy transfer, such as the historical policy context and the local cultural, economic, and bureaucratic context, which influenced whether or not a policy that was perceived to work in one place might be transferred successfully to another context. Conclusions: Theories of policy transfer provide a promising framework for characterising processes of local alcohol policy-making in England, extending beyond debates regarding evidence-informed policy to account for a much wider range of considerations. Applying a policy transfer lens enables us to move beyond simple (but still important) questions of what is supported by ¿robust¿ research evidence by paying greater attention to how policy making is carried out in practice and the multiple methods by which policies diffuse across jurisdictions.

Background: Community misconception of what causes cancer is an important consideration when devising communication strategies around cancer prevention, while those initiating social marketing campaigns must decide whether to target the general population or to tailor messages for different audiences. This paper investigates the relationships between demographic characteristics, identification of selected cancer risk factors, and associated protective behaviours, to inform audience segmentation for cancer prevention social marketing. Methods: Data for this cross-sectional study (n = 3301) are derived from Cancer Council New South Wales' 2013 Cancer Prevention Survey. Descriptive statistics and logistic regression models were used to investigate the relationship between respondent demographic characteristics and identification of each of seven cancer risk factors; demographic characteristics and practice of the seven 'protective' behaviours associated with the seven cancer risk factors; and identification of cancer risk factors and practising the associated protective behaviours, controlling for demographic characteristics. Results: More than 90% of respondents across demographic groups identified sun exposure and smoking cigarettes as moderate or large cancer risk factors. Around 80% identified passive smoking as a moderate/large risk factor, and 40-60% identified being overweight or obese, drinking alcohol, not eating enough vegetables and not eating enough fruit. Women and older respondents were more likely to identify most cancer risk factors as moderate/large, and to practise associated protective behaviours. Education was correlated with identification of smoking as a moderate/large cancer risk factor, and with four of the seven protective behaviours. Location (metropolitan/regional) and country of birth (Australia/other) were weak predictors of identification and of protective behaviours. Identification of a cancer risk factor as moderate/large was a significant predictor for five out of seven associated cancer-protective behaviours, controlling for demographic characteristics. Conclusions: These findings suggest a role for both audience segmentation and whole-of-population approaches in cancer-prevention social marketing campaigns. Targeted campaigns can address beliefs of younger people and men about cancer risk factors. Traditional population campaigns can enhance awareness of being overweight, alcohol consumption, and poor vegetable and fruit intake as cancer risk factors.

Issue addressed The aim of this study was to investigate predictors of adults' perceived acceptability of introducing alcohol to children less than 18 years of age. Methods An online survey. Logistic regression analyses were used to examine the association between demographic characteristics, alcohol consumption, and social norms and adults' own age of initiation. Results Alcohol consumption, age of initiation and perception of the acceptability of drunkenness were all correlated with the acceptability of introducing children to alcohol. The strongest predictor was adults' own age of initiation. Conclusions Adults who began drinking before the age of 18, and those who drink more heavily, are more likely to perceive the provision of alcohol to children as acceptable. So what? Policy and research should continue to focus on and monitor efforts to delay adolescent alcohol initiation and reduce consumption levels among adults. A shift in awareness and perceptions about alcohol use among adults has the potential to influence initiation and heavy drinking among adolescents.

Background and Aims: Our understanding of patient pathways through specialist Alcohol and Other Drug treatment and broader health/welfare systems in Australia remains limited. This study examines how treatment outcomes are influenced by continuity in specialist Alcohol and Other Drug treatment, engagement with community services and mutual aid, and explores differences between clients who present with a primary alcohol problem relative to those presenting with a primary drug issue. Method: In a prospective, multi-site treatment outcome study, 796 clients from 21 Alcohol and Other Drug services in Victoria and Western Australia completed a baseline interview between January 2012 and January 2013. A total of 555 (70%) completed a follow-up assessment of subsequent service use and Alcohol and Other Drug use outcomes 12-months later. Results: Just over half of the participants (52.0%) showed reliable reductions in use of, or abstinence from, their primary drug of concern. This was highest among clients with meth/amphetamine (66%) as their primary drug of concern and lowest among clients with alcohol as their primary drug of concern (47%), with 31% achieving abstinence from all drugs of concern. Continuity of specialist Alcohol and Other Drug care was associated with higher rates of abstinence than fragmented Alcohol and Other Drug care. Different predictors of treatment success emerged for clients with a primary drug problem as compared to those with a primary alcohol problem; mutual aid attendance (odds ratio = 2.5) and community service engagement (odds ratio = 2.0) for clients with alcohol as the primary drug of concern, and completion of the index treatment (odds ratio = 2.8) and continuity in Alcohol and Other Drug care (odds ratio = 1.8) when drugs were the primary drugs of concern. Conclusion: This is the first multi-site Australian study to include treatment outcomes for alcohol and cannabis users, who represent 70% of treatment seekers in Alcohol and Other Drug services. Results suggest a substantial proportion of clients respond positively to treatment, but that clients with alcohol as their primary drug problem may require different treatment pathways, compared to those with illicit drug issues, to maximise outcomes.

Background: Schools provide opportunities for parents and the wider community to connect and support the physical and emotional wellbeing of their children. Schools therefore have the potential to play a role in the socialisation of alcohol use through school policies and practices regarding consumption of alcohol by adults at school events in the presence of children. Methods: This survey was undertaken to a) compare the extent to which alcohol is used at secondary school events, when children are present, in the states of New South Wales (NSW) and Victoria (VIC), Australia; b) describe principals' level of agreement with these practices; c) their awareness of state policies on this issue; and d) the predictors of such events. A random sample of secondary schools, stratified to represent metropolitan and non-metropolitan schools were invited to participate. Bivariate and multivariate analysis were conducted with p values < 0.05 considered significant. Results: A total of 241 (43 %) schools consented to participate in the study. Fifteen percent of participating NSW schools and 57 % of VIC schools held at least one event in which alcohol was consumed by adults in the presence of children in the year before the survey. Of the 100 reported events, 78 % were Year 12 graduation dinners, and 18 % were debutante balls. Compared to NSW principals, VIC principals were significantly more likely to agree with the use of alcohol at these events; significantly less likely to be aware of their state education department policy on this issue; have a policy at their own school or support policy that prohibits alcohol use at such events; and less likely to report having enough information to make decisions about this. Conclusions: There is a growing focus on adults' use of alcohol at school events when children are present. Schools can play an important role in educating and socialising children about alcohol via both the curriculum and policies regarding adults' alcohol use at school events. Findings from this study suggest education department and school-based policies that prohibit or restrict the use of alcohol, are significant predictors of adults' alcohol use at school events when children are present.

© Published by the BMJ Publishing Group Limited.Objective Parents, schools and the broader community influence children's socialisation to alcohol. In Australia, the UK and the USA, there have been media reports of adults consuming alcohol at family-focused school events such as fairs and graduations. The aim of this qualitative study was to describe school principals' experiences of adults' use of alcohol at school events, when children are present. Design/setting/participants A qualitative study was undertaken. Publicly available lists were used to invite 60 principals from government and Catholic secondary schools in Victoria, Australia. In-depth interviews were conducted and analysed thematically and reported using the Consolidated Criteria for Reporting Qualitative Research guidelines. Results 14 principals (5 female, 9 male) participated. Most (10) of the participating principals reported adults' use of alcohol at events when students were present. Regarding these events, most principals reported concerns regarding potential harms and responsibility for decision-making about alcohol availability in schools. Some (4) principals believed alcohol should not be present at such events and this was their practice. Half of the participating schools had recently made changes to reduce the availability or management of alcohol at school functions. Conclusions The findings confirm the common use of alcohol by adults at school events, the challenges this poses for school principals and suggests consideration needs to be given to identifying strategies for supporting schools and school principals in decision-making regarding the conduct of such events.

Cumulative impact policies (CIPs) are widely used in UK local government to help regulate alcohol markets in localities characterised by high density of outlets and high rates of alcohol related harms. CIPs have been advocated as a means of protecting health by controlling or limiting alcohol availability. We use a comparative qualitative case study approach (n=5 English local government authorities, 48 participants) to assess how CIPs vary across different localities, what they are intended to achieve, and the implications for local-level alcohol availability. We found that the case study CIPs varied greatly in terms of aims, health focus and scale of implementation. However, they shared some common functions around influencing the types and managerial practices of alcohol outlets in specific neighbourhoods without reducing outlet density. The assumption that this will lead to alcohol harm-reduction needs to be quantitatively tested.

Background: People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC. Methods: Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests. Results: Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC. Conclusions: While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Background: Public knowledge of the association between alcohol and cancer is reported to be low. We aimed to provide up-to-date evidence for England regarding awareness of the link between alcohol and different cancers and to determine whether awareness differs by demographic characteristics, alcohol use, and geographic region. Methods: A representative sample of 2100 adults completed an online survey in July 2015. Respondents were asked to identify which health outcomes, including specific cancers, may be caused by alcohol consumption. Logistic regressions explored whether demographic, alcohol use, and geographic characteristics predicted correctly identifying alcohol-related cancer risk. Results: Unprompted, 12.9% of respondents identified cancer as a potential health outcome of alcohol consumption. This rose to 47% when prompted (compared to 95% for liver disease and 73% for heart disease). Knowledge of the link between alcohol and specific cancers varied between 18% (breast) and 80% (liver). Respondents identified the following cancers as alcohol-related where no such evidence exists: bladder (54%), brain (32%), ovarian (17%). Significant predictors of awareness of the link between alcohol and cancer were being female, more highly educated, and living in North-East England. Conclusion: There is generally low awareness of the relationship between alcohol consumption and cancer, particularly breast cancer. Greater awareness of the relationship between alcohol and breast cancer in North-East England, where a mass media campaign highlighted this relationship, suggests that population awareness can be influenced by social marketing.

Objectives To evaluate short-term effects of publishing revised lower risk national drinking guidelines on related awareness and knowledge. To examine where drinkers heard about guidelines over the same period. Design Trend analysis of the Alcohol Toolkit Study, a monthly repeat cross-sectional national survey. Setting England, November 2015 to May 2016. Participants A total of 11 845 adults (18+) living in private households in England. Intervention Publication of revised national drinking guidelines in January 2016 which reduced the male guideline by approximately one-third to 14 units per week. Measurements Whether drinkers (1) had heard of drinking guidelines (awareness), (2) stated the guideline was above, exactly or below 14 units (knowledge) and (3) reported seeing the stated guideline number of units in the last month in each of 11 locations (exposure). Sociodemographics: sex, age (18-34, 35-64, 65+), social grade (AB, C1C2, DE). Alcohol consumption derived from graduated frequency questions: low risk (<14 units/week), increasing/high risk (14+ units/week). Results Following publication of the guidelines, the proportion of drinkers aware of guidelines did not increase from its baseline level of 85.1% (CI 82.7% to 87.1%). However, the proportion of male drinkers saying the guideline was 14 units or less increased from 22.6% (CI 18.9% to 26.7%) in December to 43.3% (CI 38.9% to 47.8%) in January and was at 35.6% (CI 31.6% to 39.9%) in May. Last month exposure to the guidelines was below 25% in all locations except television/radio where exposure increased from 33% (CI 28.8% to 36.2%) in December to 65% (CI 61.2% to 68.3%) in January. Awareness and knowledge of guidelines was lowest in social grade DE and this gap remained after publication. Conclusions Publication of new or revised lower risk drinking guidelines can improve drinkers' knowledge of these guidelines within all sociodemographic groups; however, in the absence of sustained promotional activity, positive effects may not be maintained and social inequalities in awareness and knowledge of guidelines are likely to persist.

Environmental and societal factors are significant determinants of children's initiation to and use of alcohol. Schools are important settings for promoting well-being and substantial resources have been devoted to curriculum-based alcohol programs, but the effects of these in reducing the misuse of alcohol have been modest. Adults can and do consume alcohol at school events when students are present, but there is a dearth of evidence about parents' level of support for the practice. The aim of this study was to examine parents' level of support for the purchase and consumption of alcohol at primary school fundraising events when children are present. Methods: Four hundred seventy-nine Australian parents of children aged 0-12 years participated in an online survey. Logistic regression was used to assess the impact of parent characteristics on the level of agreement with parental purchase and consumption of alcohol at school fundraising events when children are present. Results: The majority of parents (60%) disagreed/strongly disagreed with the practice of adults being able to purchase and consume alcohol at school fundraising events when children were present. The 21% of parents who supported the practice were more likely to be daily smokers and/or have higher (>6) Alcohol Use Disorders Identification Test-alcohol consumption scores. Conclusions: Despite the fact that the majority of parents disagree with this practice, published reports suggest that adults' use of alcohol at primary school events is an emerging issue. It is important that school decision-makers are mindful of the financial and educational value of fundraising activities.

Background: Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder. Objectives: To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care. Search methods: We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies. Selection criteria: We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care. Data collection and analysis: Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information. We collected and analysed data for all follow-up periods: up to and including three months following the start of treatment; between three and 12 months; and more than 12 months following the start of therapy. We used a random-effects model to calculate the risk difference (RD) for binary data and number needed to treat for an additional beneficial outcome (NNTB), if differences between groups were significant. The mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data. Main results: There were 8203 citations identified from database searches and reference lists. We included 12 trials with 2605 consumer participants and more than 905 primary care practitioner participants. Eleven trials compared consultation liaison to standard care and one compared consultation liaison to collaborative care, with a case manager co-ordinating mental health care. People with depression were included in eight trials; and one trial each included people with a variety of disorders: depression, anxiety and somatoform disorders; medically unexplained symptoms; and drinking problems. None of the included trials reported separate data for children or older people. There was some evidence that consultation liaison improved mental health up to three months following the start of treatment (two trials, n = 445, NNTB 8, 95% CI 5 to 25) but there was no evidence of its effectiveness between three and 12 months. Consultation liaison also appeared to improve consumer satisfaction (up to three months: one trial, n = 228, NNTB 3, 95% CI 3 to 5; 3 to 12 months: two trials, n = 445, NNTB 8, 95% CI 5 to 17) and adherence (3 to 12 months: seven trials, n = 1251, NNTB 6, 95% CI 4 to 13) up to 12 months. There was also an improvement in the primary care provider outcomes of providing adequate treatment between three to 12 months (three trials, n = 797, NNTB 7, 95% CI 4 to 17) and prescribing pharm...

Issue addressed: Schools are recognised as important settings for promoting student and community wellbeing through education, policies and the modelling of behaviour. Recently, there has been controversy regarding the promotion and use of alcohol by adults at school events. The aim of this study was to examine the policy approach of all Australian jurisdictions to the possession and use of alcohol, by adults, at government school events when students are present. Methods: A desktop review of Australian governments' alcohol in schools policy/guidelines documents was undertaken. Results: Eighteen documents across eight jurisdictions were retrieved. There were inconsistencies between jurisdictions and lack of policy clarity regarding the promotion and/or use of alcohol by adults at events organised by schools for recreation, celebration and fundraising purposes. Discussion and conclusions: Clarity is needed about the role of alcohol in Australian schools, particularly in relation to its use of alcohol when there is a duty of care to children. The possession and/or use of alcohol by adults at school events may contribute to the pervasive role of drinking in Australian social life. So what?: Clear and evidence-based guidelines are needed to inform school policies across all jurisdictions as to whether, when and under which circumstances it is appropriate for schools to promote and/or supply alcohol. This would also strengthen the ability of school principals and communities to make appropriate evidence-based decisions that focus on the interests of children.

This paper provides a comprehensive review of the key dimensions of access and their significance for the provision of primary health care and a framework that assists policy-makers to evaluate how well policy targets the dimensions of access. Access to health care can be conceptualised as the potential ease with which consumers can obtain health care at times of need. Disaggregation of the concept of access into the dimensions of availability, geography, affordability, accommodation, timeliness, acceptability and awareness allows policy-makers to identify key questions which must be addressed to ensure reasonable primary health care access for rural and remote Australians. Evaluating how well national primary health care policies target these dimensions of access helps identify policy gaps and potential inequities in ensuring access to primary health care. Effective policies must incorporate the multiple dimensions of access if they are to comprehensively and effectively address unacceptable inequities in health status and access to basic health services experienced by rural and remote Australians. © 2013 The Authors. Australian Journal of Rural Health © National Rural Health Alliance Inc.

Background: There are significant health status inequalities in Australia between those people living in rural and remote locations and people living in metropolitan centres. Since almost ninety percent of the population use some form of primary health care service annually, a logical initial step in reducing the disparity in health status is to improve access to health care by specifying those primary health care services that should be considered as "core" and therefore readily available to all Australians regardless of where they live. A systematic review was undertaken to define these "core" services. Using the question "What primary health care services should residents of rural and remote Australia be able to access?", the objective of this paper is to delineate those primary health care core services that should be readily available to all regardless of geography. Method. A systematic review of peer-reviewed literature from established databases was undertaken. Relevant websites were also searched for grey literature. Key informants were accessed to identify other relevant reference material. All papers were assessed by at least two assessors according to agreed inclusion criteria. Results: Data were extracted from 19 papers (7 papers from the peer-reviewed database search and 12 from other grey sources) which met the inclusion criteria. The 19 papers demonstrated substantial variability in both the number and nature of core services. Given this variation, the specification or synthesis of a universal set of core services proved to be a complex and arguably contentious task. Nonetheless, the different primary health care dimensions that should be met through the provision of core services were developed. In addition, the process of identifying core services provided important insights about the need to deliver these services in ways that are "fit-for-purpose" in widely differing geographic contexts. Conclusions: Defining a suite of core primary health care services is a difficult process. Such a suite should be fit-for-purpose, relevant to the context, and its development should be methodologically clear, appropriate, and evidence-based. The value of identifying core PHC services to both consumers and providers for service planning and monitoring and consequent health outcomes is paramount. © 2013 Carey et al.; licensee BioMed Central Ltd.

Medication overdose is a common method of non-fatal self-harm. Previous studies have established which mental health disorders are commonly associated with the behaviour (affective, substance use, anxiety and personality disorders) and which medications are most frequently implicated (benzodiazepines, antidepressants, antipsychotics and non-opioid analgesics). However, few studies have explored patient experiences of medication overdose. We address this gap by examining patient stories of a recent medication overdose event, including severity of depression, intended outcomes and patient experiences of emergency medical care, in part to determine the unmet needs of this group of patients. Semi-structured interviews were conducted with 31 patients attending an urban Emergency Department (ED) in Melbourne, Australia, following a medication overdose regarding their mental health history, state of mind at the time of the overdose, circumstances of the overdose, and experiences of emergency medical care. Participants were heterogeneous regarding the severity of depressive symptomatology at the time of overdose. Participant ratings of how accidental or deliberate the overdose was and how strongly they intended to die were also diverse. Stories relating to the overdose usually covered the themes of precipitating events, negative feeling states, and intended outcomes (ambivalent or contradictory). Few problems were identified in relation to the care received in relation to the current overdose. However, histories of extensive mental health problems were commonly reported, along with unsuccessful treatment for these. While mental health problems are common among patients attending the ED following a medication overdose, there is considerable diversity in current levels of distress and intended outcomes, indicating a thorough suicide risk assessment is always warranted. Presentation to the ED for medication overdose should also trigger a mental health treatment review. © 2011 Springer Science+Business Media, LLC.

Evidence shows the management of deteriorating patients needs to be improved, particularly in midwifery care. In a series of three simulation-based studies in Australia we examined qualified nurses', student nurses' and midwives' ability to manage patient deterioration. Nurses' knowledge levels were acceptable but their skill performance was low and there was a gap between the theory and practice they had experienced. In these high-pressure situations, demographic factors (including educational level) had no impact on their performance, which suggests they need repetitive "high-stakes" simulation, improved feedback mechanisms and enhanced educational processes.

Introduction and Aims: To describe the characteristics of non-fatal medication-related ambulance attendances in Melbourne. Design and Methods. A retrospective analysis of 16 705 patient care records completed by ambulance paramedics in Melbourne where medications had a causal role in the attendance. Results. A single medication only was implicated in 11 765 cases (70% of the total). Of these, 85% involved one of six types of medication: benzodiazepines (52%), paracetamol (15%), selective serotonin re-uptake inhibitors (6.5%), combination paracetamol and opioids (4%), phenothiazines (3.4%) and tricyclic antidepressants (TCA) (3.7%). Cases involving benzodiazepines were significantly (P < 0.001) older (Average = 37 years) than those involving paracetamol (Average = 30 years). Thirty-four per cent of cases involved concurrent alcohol use, and this varied according to drug type (paracetamol 26%, benzodiazepines 40%, selective serotonin re-uptake inhibitors 35%, paracetamol and opioids 35%). An abnormal Glasgow Coma Scale score was found in 19% of cases, again varying according to drug type (paracetamol 10%, TCA 39%, benzodiazepines 21%, paracetamol and opioids 17%, phenothiazines 15%). Ten per cent of cases were not transported to hospital ranging from 3% for TCA to 13% for benzodiazepines. Discussion and Conclusions. The majority of non-fatal medication events attended by ambulance paramedics involve one of six substances. Benzodiazepines were most commonly implicated and, as management may require only simple supportive treatment, significant numbers are not transported to hospital. The unique clinical population is identified in this study and the ongoing medical and psychiatric treatment of these patients not transported to hospital in the study period needs to be considered. © 2009 Australasian Professional Society on Alcohol and other Drugs.

Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care.Objective: This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia.Design: A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria.Results: While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required.Conclusions: This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre- and post-intervention comparisons.© 2010 The Authors. Journal compilation © 2010 National Rural Health Alliance Inc.

Objective: This study aimed to investigate which categories of medication are most commonly implicated in overdose, to compare this information with prescription data and to explore how the medications used in overdoses are typically acquired. Methods:A 12-month audit (11/2003- 10/2004) of all medication overdose presentations to an inner-Melbourne ED was conducted and the medications compared to published population- based prescription data. Interviews were conducted with 31 patients who attended the ED following a medication overdose and typical stories regarding the acquisition of medications reported. Results:The same broad categories of medications identified in earlier studies were found to contribute to the majority of overdoses in this study, namely benzodiazepines, antidepressants, analgesics and antipsychotics. Two benzodiazepine medications, diazepam and alprazolam, appeared to be over- represented in the overdose data relative to their population rates of prescription. Patient interviews revealed three main reasons for the original acquisition of the medications used in overdose: treatment purposes (77%); recreational use (16%); and overdose (7%).The most common source of medications (68%) used in overdose was prescription by the patient's usual doctor. Conclusion:The high representation of benzodiazepines among medications used in overdose is of ongoing concern. Implications:The time of medication prescription and dispensing may be an ideal opportunity for overdose prevention, through judicious prescribing, consideration of treatment alternatives, patient education and encouraging the safe disposal of unused medications. © 2010 Public Health Association of Australia.

Background: Medication overdose accounts for >80% of hospital presentations for self-harm. Previous research has identified typical characteristics of medication overdose cases; however, these cases have not been well differentiated from other similar presentations, namely (1) illicit drug overdose and (2) self-harm by means other than overdose. Method: A 12-month audit of medication overdose cases (both intentional and unintentional) attending the emergency department (ED) of a major metropolitan public hospital in Melbourne, Australia was conducted. Comparison was made with patients attending for illicit drug overdose or for self-harm by means other than overdose. Results: Medication overdose cases (n=453) showed a broadly comparable profile with those found in earlier studies (predominantly female gender, aged in their 30s and referred for psychosocial assessment). A similar though not identical profile was noted for self-harm cases (n=545). In contrast, patients attending for illicit drug overdose (n=409) could be characterised as male, in their 20s and not referred for psychosocial assessment. Illicit drug overdose cases were more likely than either the medication overdose or self-harm cases to be triaged in the most urgent category (19.3, 3.8 and 3.9% respectively), suggesting a high level of acuity in this group. However, the illicit drug overdose group on average spent less time in the ED than medication overdose patients, and were less likely to require hospital admission. Conclusion: On both demographic and treatment variables, patients attending the ED following a medication overdose more closely resemble those attending for self-harm by means other than overdose than those attending for illicit drug overdose.

Objectives: To describe epidemiology, symptomatology, resource use and complications in patients attending the ED following gamma-hydroxybutyrate (GHB) ingestion. Methods: Retrospective chart review of GHB-related emergency attendances over 30 months. Results: One hundred and seventy emergency attendances attributed to GHB ingestion occurred. Monthly attendance rate doubled during the study, and was highest on public holidays and weekends between 04.00 and 08.00 hours. The majority (63%, 95% CI 55.7-70.3) were young men (median 22 years). GHB was ingested alone in 62 cases (36%, 95% CI 29.6-43.9). Poly-substance ingestion was common (108 cases; 64%; 95% CI 56.1-70.4). The commonest presenting symptom was altered conscious state (89%, 95% CI 84.1-93.5) with 54% (95% CI 46.6-61.6) having low Glasgow Coma Score (GCS 3-8) on arrival at the ED. Eight per cent (95% CI 3.6-11.6) were intubated. Eighty-seven per cent (95% CI 79.8-93.8) with low GCS were not intubated. There were no serious adverse outcomes or fatalities. Recovery time from ED arrival to high GCS (9-15) was rapid (median 76 min, interquartile range 80). Overall median length of stay was 199 min (interquartile range 162). Conclusions: This is the largest GHB-related case series to date. Attendance rate doubled during the study, and peaked at times of lowest staffing. Poly-substance ingestion is common. Attendances are of high acuity with decreased conscious state and airway threat. With close conservative management, most recover quickly without adverse sequelae. © 2008 The Authors.

Previous studies have reported varying rates of intentional overdose among heroin overdose survivors. This article reports on the prevalence of intentional heroin overdose among a sample of overdose survivors in Melbourne, Australia. This is part of a larger study examining the risk factors associated with nonfatal overdose. The study involved interviews with 256 heroin overdose survivors successfully resuscitated by Melbourne Ambulance Service paramedics. A substantial minority (17%) of the sample indicated that they had ever had an intentional overdose, and 67% had one within the last 6 months (11% of the total sample). Of those who had ever intentionally overdosed, 21% did so at the overdose for which they were recruited into the study (4% of total sample). Self-reported reasons for intentional heroin overdose fell into two categories: precipitating events and emotional states prior to use. Intentional overdose appears to comprise a relatively low proportion of overall heroin overdoses. However, given the complexity of suicidal thought and behavior, it is possible that some heroin overdose survivors who report their overdose to be unintentional were in fact experiencing some degree of suicidal thinking at the time of the overdose. Future research could address the potentially ambiguous nature of some intentional heroin overdoses.

The purpose of the study was to provide updated estimates of alcohol-caused mortality rates in Australia between 1990 and 1997, making adjustments for changes in the prevalence of high-risk alcohol use estimated on the basis of per capita alcohol consumption (PCAC). Deaths wholly and partially attributable to high-risk alcohol consumption were extracted from the Australian Bureau of Statistics Mortality Datafile (1990-1997) and multiplied by specific aetiological fractions, which in turn were adjusted by changes in the prevalence of high-risk alcohol use estimated on the basis of annual changes in PCAC. The yearly trends in age-standardized rates of estimated alcohol-caused deaths were compared with those using (i) aetiological fractions unadjusted for changes in PCAC, and (ii) wholly alcohol-caused conditions only (thus requiring no application of aetiological fractions). The age-standardized rates of all alcohol-caused deaths among males aged 15 + years declined from 1990 (4.01/10000) to 1993 (3.19/10000) and decreased far more slowly up to 1997 (3.15/10000)-16% overall. For females, these rates declined steadily from 1990 (1.75/10000) to 1997 (1.33/10000)-19% overall. Similar patterns in time trends were noted for estimated alcohol-caused death rates calculated as in (i) and (ii). However, the proportional decreases in rates (21.6% for males; 24.0% for females) would have been underestimated by 16% (males) and 19% (females) if the alcohol aetiological fractions had not been adjusted to take account of the estimated annual changes in the prevalence of high-risk drinking. The declines in estimated alcohol-caused death rates were more pronounced than the 9% decline in PCAC, and were due mainly to decreasing death rates for stroke (men and women), alcoholic liver cirrhosis and road injuries (men only). When aetiological fractions are used to measure temporal trends in estimated alcohol-caused death rates from official mortality statistics, they should account for annual changes in the prevalence of high-risk drinking. Such changes in prevalence can be deduced from yearly fluctuations in PCAC.

Objectives: (i) To estimate the numbers of deaths and person-years of life lost (PYLL) due to high-risk alcohol consumption in Australia during 1997, using current estimates of consumption. (ii) To compare the number of deaths and PYLL due to acute conditions associated with bouts of intoxication and chronic conditions associated with long-term misuse of alcohol. Methods: All Australian deaths during 1997 related to conditions considered to be partially or wholly caused by high-risk alcohol consumption were extracted from the Australian Bureau of Statistics Mortality Datafile and adjusted by alcohol aetiologic fractions calculated for Australian in 1997. A life-table method was used to estimate the PYLL for deaths from alcohol-caused conditions. Main outcome measures: Numbers of all deaths and PYLL due to chronic and acute alcohol-related conditions. Results: Of the 3290 estimated alcohol-caused deaths in 1997, chronic conditions (eg, alcoholic liver cirrhosis and alcohol dependence) accounted for 42%, acute conditions (eg, alcohol-related road injuries and assaults) for 28% and mixed (chronic and acute) for 30%. Of the 62 914 estimated potential life years lost, acute conditions were responsible for 46%, chronic for 33% and mixed for 21%. The average number of years of life lost through deaths from acute conditions was more than twice that from chronic conditions, because the former mostly involved younger people. Conclusions: In view of the societal burdens imposed by premature deaths, more effective public health strategies are needed to reduce the harm associated with occasional high-risk drinking (as well as sustained high-risk drinking), especially among young people.

The Court Referral and Evaluation for Drug Intervention and Treatment programme (CREDIT) was developed by a small group of magistrates at the Melbourne Magistrates' Court who wished to address the high rate of re-offending while on bail noted among illicit drug using offenders. An evaluation was conducted of the first 9 months' operation of the programme. The evaluation involved an analysis of key performance indicators (client uptake of CREDIT, retention in and satisfactory completion of treatment, the extent of re-offending while on bail) and interviews with 30 key informants and six programme participants. Despite a lack of conclusive evidence regarding the efficacy of the programme according to the identified key performance indicators, key informant interviews revealed a high level of support for the continuation of the programme.

A sample of 605 South Australian residents was surveyed in 1997 regarding the Cannabis Expiation Notice (CEN) System. Thirty-nine per cent had ever used cannabis and 14.5% used cannabis at least once a year. While only 17% knew of the CEN scheme, 76% were familiar with the 'on-the-spot fine' scheme. There was confusion about the legal status of two expiable offences; 24% thought possession of less than 100g of cannabis was legal and 53% thought growing three plants was legal. Only 40% knew that the two expiable offences involved some legal sanction. Regarding attitudes to cannabis law, the majority thought that growing 15 plants, selling 25g for profit, possession of less than 100g by a juvenile and driving while affected by cannabis should remain illegal. Eighty per cent thought medical use of cannabis should be legal. Half of the sample thought that growing three plants and possession of less than 100g of cannabis should be legal and most of those who thought the two offences should be illegal said a fine was the appropriate penally. Most people (57%) thought the cannabis laws should either remain as they are or become less strict, indicating general support for expiation.

Quantitative data is reported from a study of 68 South Australians who had received an infringement notice or 'cannabis expiation notice' (CEN) and 68 West Australians who received a criminal conviction for a minor cannabis offence not more than 10 years ago to compare impact of the infringement notice and the conviction on their lives. The majority of both groups saw themselves as largely law-abiding, had respect for the law in general and had positive views regarding cannabis. However, more of the convicted group, compared to the infringement notice group, reported negative employment consequences (32% vs. 2%), further problems with the law (32% vs. 0%), negative relationship consequences (20% vs. 5%) and accommodation consequences (16% vs. 0%) as a result of their apprehension. While neither conviction nor infringement deterred subsequent cannabis use for the vast majority, the negative social impacts of conviction were far greater than those resulting from an infringement notice. The findings have implications for the legislative options for regulation of cannabis possesssion and use.