ESCUELA ACADEMICO PROFESIONAL DE OBSTETRICIA

Appendix J - Key informant participant information and consent

Appendix K - Key informant interview questions (Version 1 and 2)

Appendix L - Advisory committee invitation

Appendix M - Ontario public health unit survey coding analysis

Appendix N - Key informant interview coding analysis

Appendix O - Major Disease and Injury Categories Causally Linked to Alcohol

Appendix P - Ontario Public Health Standards and Alcohol

Appendix Q - Potential Stakeholders for PHU Partnership

Appendix R - Ontario public health unit survey summary

Appendix S - The Health Communication Resource Centre Policy Road Map

Appendix T - Quick Reference Instrument Guide

Appendix U - Alcohol Screening, Brief Intervention and Referral: A Clinical Guide

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Appendix A

Research Methodology

The research and writing team chose to utilize a narrative synthesizes approach in writing this report. This approach systematically reviews and synthesis information from many different studies while using narrative text to summarize these ndings (Popay et al., 2006). The approach is used where the “review question dictates the inclusion of a wide range of research designs, producing qualitative and/or quantitative

ndings for which other approaches to synthesis are inappropriate” (Popay et al., 2006) Pg. 7. It was therefore chosen due to its strength in

summarizing the current knowledge around a question from several different sources and portraying that knowledge through a narrative, storytelling approach.

Through a narrative process, evidence on the effectiveness of interventions on alcohol consumption and alcohol-related harms was explored. This data was then triangulated with data from a survey of Ontario PHUs and interviews with key informants to further explore the effectiveness of these interventions as well as the barriers and facilitators to their implementation at the local level.

The research and writing team chose to focus on systematic reviews and exclude all primary studies from the literature search; therefore the analysis of the data did not review the effect size of individual interventions. This choice was made in order to compile the high level evidence within the broad eld of primary public health interventions to reduce alcohol consumption and alcohol-related harms. In comparing and contrasting systematic reviews and triangulating this data with the other data collected in the report the research team was able to summarize the available evidence in order to enable those working in the eld to take action.

Systematic Review Literature

Search Strategy

Electronic databases were searched to retrieve relevant systematic reviews. Databases searched included: Academic Search Premier, CINAHL with Full Text, Global Health, MEDLINE, Nursing & Allied Health Collection: Comprehensive, Psychology and Behavioral Sciences Collection, Cochrane Database of Systematic Reviews, PubMed, PsycINFO, Health Evidence, TRIP

Database, Environment Complete, and SocINDEX with Full Text.

The search strategy used the following MeSH terms: alcoholic; alcoholism; automobile driving; consumer participation; cost-benet analysis; evidence-based practice; harm reduction; health education; health policy; health promotion; health services needs and demand; information services; program evaluation; social marketing; taxes; mass media.

Systematic Review Literature

Search Results

The initial search of electronic databases retrieved 7000+ articles. Based on these results the research team rened their search

parameters and identied inclusion and

exclusion criteria (Table 1). Using the new search parameters the research team narrowed the list of articles to 300. Screening of the titles and abstracts of these articles identied 18 systematic reviews for full text review. An additional ten systematic reviews were identied using hand searching, review of reference lists and consultation with content experts. (Figure 2).

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Quality Assessment

Twenty-eight full text systematic reviews were retrieved and reviewed for quality and content by eight researchers. Quality review was

completed using the Health Evidence Quality Assessment Tool (Appendix G) (McMaster University: Health Evidence, 2013). The tool facilitates assessment of systematic reviews for the rigor and transparency of the review. Articles were rated as strong (total score 8-10), moderate (total score 5-7) or weak (total score 4 or less). Discrepancies in article rating were reconciled through discussion among the research team. Articles rated as weak or not meeting the inclusion and exclusion criteria

were excluded from the review.

Following full text review and application of the Health Evidence Quality Assessment Tool, ten systematic reviews were eliminated: three were systematic reviews with no relevant

interventions or outcomes; one was rated as weak; four were summaries of systematic reviews that were already included; one was a protocol for a systematic review and one was not a systematic review. Of the 18 systematic reviews identied for data extraction, 16 were rated as strong by the Health Evidence Quality Assessment tool and two were rated as

moderate. Results of the systematic review literature search are outlined in Figure 1.

Systematic Reviews

Inclusion Exclusion

systematic review; English; focuses on effectiveness of primary or secondary public health strategy(ies) to decrease alcohol consumption and/or alcohol-related harms (on violence, disease and injury and

drinking and driving outcomes)

before 2004; primary studies; tertiary care interventions; addiction and long-term treatment; rated as weak by the Health Evidence Quality Assessment tool

Systematic Reviews (electronic databases) N = 7000+ Revised Systematic Reviews N = 300 Systematic Reviews (electronic search) N = 18 Systematic Reviews (manual citation search and content experts consultation) N = 10 Excluded (10): 1: weak rating 1: protocol of systematic review 3: no relevant intervention 1: not a systematic review 4: summary of systematic review

Excluded (282): Title and/or abstract do not meet inclusion criteria

Included systematic reviews N = 18

Full text Systematic Reviews N = 28

FIGURE 1: Systematic review literature search

Data Extraction and Synthesis

Data regarding the information on intervention type, intervention components, outcomes, setting, barriers and facilitators of the 18

systematic reviews was identied and extracted by two researchers using a standardized data abstraction form. Four of 18 systematic reviews were reviewed by both researchers to ensure inter-rater reliability. The remaining 14

systematic reviews were split equally between the two researchers. All information on the systematic reviews was recorded in Appendices B, C and D.

Interventions to reduce alcohol consumption and alcohol-related harm were categorized into the following themes: (Appendix B).

· Pricing and taxation

· Regulating physical availability

· Modifying the drinking environment

· Drinking-driving countermeasures

· Restrictions on marketing

· Education and persuasion

· Treatment and early intervention Categories were dened according to broad intervention areas that arose from Alcohol: No Ordinary Commodity—Research and Public Policy, 2nd ed. by Babor et. al. (2010). The impact of the identied interventions on the pre-dened outcomes was then expanded upon in Appendix D. These ndings are further synthesized and elaborated on throughout the report using a narrative synthesis approach.

Grey Literature

The approach to using the grey literature in the development of this report was to validate and supplement the ndings from systematic reviews. Documents were consulted to explore the work currently being done in the eld of alcohol prevention and apply the

recommendations from the grey literature to the ndings of this research.

Through manual citation searching and

consultation with content experts the research and writing team identied 44 relevant grey literature sources for inclusion in the report. Grey literature relevancy was determined through group consensus with consideration of the following criteria: level of evidence, language (English), relevancy to public health, focus on primary or secondary public health strategy(ies) to decrease alcohol consumption and/or

alcohol-related harms as well as any potential sources for bias.

Public Health Unit Surveys

Ontario public health units were surveyed to determine what actions they are taking within a comprehensive approach to reduce alcohol- related harms and the practical knowledge and supports they required to be more effective in their work at the local level.

The project team tailored survey questions under three broad, generic questions which must be asked as part of a situational

assessment (Public Health Ontario, Dalla Lana School of Public Health, 2012).

· What is the situation (trends, public and stakeholder perception and concerns etc.)?

· What is making the situation better and worse?

· What possible actions can you take to deal with the situation?

Eighteen open and close-ended questions were created in Select Survey software (Appendix I). The survey link was emailed with a cover letter to the Medical Ofcer of Health of each public health unit across Ontario.

A total of 36 surveys were sent. The Medical Ofcers of Health were asked to direct the survey to the most appropriate individual or group to complete the questions within their respective health unit. Public health units were given up to three weeks to complete the survey. Reminder emails were sent to the Medical

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Ofcers of Health one week after the survey launch date and approximately three days prior to the survey response deadline.

Thirty-two anonymous responses were received for a response rate of 89 percent. Respondents included but were not limited to public health nurses, injury prevention managers, health promoters and/or planners and the Medical Ofcer of Health.

Survey responses for the open-ended questions were manually coded by two project

participants to determine code categories and denitions related to the work currently being done in regards to alcohol, as well as the barriers and facilitators to this work. Responses were then coded through the NVivo 10 software by an internal public health staff with research and data analysis experience. This individual

consulted with and used the codes developed by the two original coders. Results of the manual coding and the NVivo 10 software coding were compared to decrease the risk of interpretation bias. Inter-rater reliability was tested between the manual coding and the NVivo 10 software coding. (Appendix M)

Extracted data and themes were used to highlight barriers and facilitators when

implementing alcohol programming at the local level.

Key Informant Interviews

Key informants were an essential part of the project's comprehensive data collection strategy. They allowed the working group to gather information about the current political,

economic, environmental and social context as well as the historical development of alcohol control in Ontario. Relevant evidence and experience from other provinces in Canada as well as from the area of tobacco control in Ontario, was also gathered.

Purposive sampling was the methodology used to create a list of potential key informants.

Potential candidates were chosen based on their

expertise and knowledge of alcohol at the local, provincial or national level. Those that had knowledge and expertise in tobacco control were also considered. Key informants were recruited by letter. The recruitment letter was followed up by a reminder email invitation one week later.

The key informants interviewed included nine national experts in alcohol and tobacco prevention. Six experts were from the eld of alcohol prevention and three experts in the area of tobacco prevention. A list of key informants is included in the acknowledgements.

Key informant interview questions were designed using the following resources:

· Resource manual on qualitative research, (Bourgeault, Rolfe, & Runnels, 2013)

· Safety diagnosis tool kit for local

communities: Guide to organizing semi- structured interviews with key informants, (Laforest, 2009)

· Manual for training interviewers, (Runnels, 2013)

· Getting the lay of the land on health: A guide for using interviews to gather information, (Sherry & Marlow, 1999)

· Needs assessment techniques, (University of Illinois Extension Service - Ofce of Program Planning and Assessment) The working group structured ten open-ended questions for the ve key informants that had knowledge and expertise in the topic of alcohol and ten open-ended questions for the four key informants that had knowledge and expertise in the topic of tobacco control (Appendix K).

Interviews were conducted by three researchers and one student involved in the project.

Structured questions and probes were used by all interviewers to help ensure consistency in the interviewing process. All interviews were

recorded and transcribed by CMBusiness & Transcription Services.

Interviews were manually coded by two project participants. An internal public health staff with

research and data analysis experience also coded the interviews through the NVivo 10 software in consultation with the two original coders. Results of the manual coding and the NVivo 10 software coding were compared to decrease the risk of interpretation bias. Inter- rater reliability was tested between the manual coding and the NVivo 10 coding. (Appendix N). Extracted data and themes were used to gain an understanding about alcohol within a local, provincial or national context and were used to help shape recommendations made in this report.

Advisory Committee

The advisory committee members were recruited from the group of key informants by implied consent. Nine who agreed to act in an advisory role were sent a letter of participation and information about the scope of the project by email (Appendix L).

Once established, the advisory committee was updated by teleconferences and emails about the project's progress. The committee was asked to provide input and feedback on the report through teleconference meetings as well as a written survey.

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Appendix B

Systematic Review Chart 1: Themes for Evidence Based Action Available online at: www.oninjuryresources.ca/ldcpalcohol

Appendix C

Systematic Review Chart 2: Characteristic's and Quality of Systematic Reviews Available online at: www.oninjuryresources.ca/ldcpalcohol

Appendix D

Systematic Review Chart 3: Summary of Results

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Appendix E

Systematic Review Chart 4: Excluded systematic reviews

Reason for exclusion

Source

Weak rating Popova, S., Giesbrecht, N., Bekmuradov, D., & Patra, J. (2009). Hours and days of sale and density of alcohol outlets: Impacts on alcohol

consumption and damage: A systematic review. Alcohol and Alcoholism,

44(5), 500-516.

Protocol of a systematic review

Carney, T., Myers, B.J., & Louw, J. (2011). Brief school -based interventions and behavioural outcomes for substance-using adolescents (protocol). The Cochrane Library(2).

No relevant information

Heung, C., LeMar, J., & Rempel, B. (201 0). Alcohol and community-based violence: A systematic review. Retrieved May 9, 2013, from Alcohol Policy Network Web site:

http://www.apolnet.ca/resources/pubs/rpt_Alcohol_and_Violence- 2010.pdf

No relevant information

Johnson, M., Jackson R., Guillaume, L., Meier, P., & Goyder, E. (2011).

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. Journal of Public Health,33(3), 412-421.

No relevant information

Williams, E.C., Johnson, M.L., Lapham G.T., Caldeiro, R.M., Chew, L., Fletcher, G.S., McCormick, K.A., Weppner, W.G., & Bradley, K.A. (2011). Strategies to implement alcohol screening and brief intervention in primary care settings: a structured literature review. Psychology of Addictive Behaviours, 25(2), 206-214.

Not a systematic review

Toomey, T.L., & Lenk, K.M. (2011). A review of environmental -based community interventions. Alcohol Research & Health, 34(2), 163-166.

Summary of a systematic review

Task Force on C ommunity Preventive Services. (2009). Recommendations for reducing excessive alcohol consumption and alcohol-related harms by limiting alcohol outlet density. American Journal of Preventive Medicine,

37(6), 570-571.

Summary of a systematic review

Task Force on Community Preventive Services. (2010). Increasing alcoholic beverage taxes is recommended to reduce excessive alcohol consumption and related harms. American Journal of Preventive Medicine, 38(2), 230-232.

Summary of a systematic review

Task Force o n Community Preventive Services. (2012). Recommendations on privatization of alcohol retail sales and prevention of excessive alcohol consumption and related harms.American Journal of Preventive Medicine,

42(4), 428-429.

Summary of a systematic review

Alcohol Policy Network. (2010). From evidence to action: Reducing harm from alcohol and community-based violence. Retrieved May 9, 2013, from Alcohol Policy Network Web site:

http://www.apolnet.ca/resources/pubs/respapers/FromEvidenceToAction - Jun2010.pdf

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Appendix F

Grey Literature Chart 1

Grey Literature from literature search

Anderson, P., Chisholm, D., & Fuhr, D. C. (2009). Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet, 373(9682), 2234. doi:10.1016/S0140- 6736(09)60744-3

Babor, T., Caetano, R., Cassell, S., Edwards, G., Giesbrecht, N., Graham, K., & Rossow, I. (2010). Alcohol no ordinary commodity research and public policy (second ed.). New York, USA: Oxford University Press. Bailey, J., Poole, R., Zinovieff, F., Robinson, C., Parry, O., Tocque, K., & Kennedy, L. (2011). Achieving positive change in the drinking culture of Wales. Wales: Glyndwr University, Bangor University.

British Columbia Ofce of the Provincial Health Ofcer. (2008). Public health approach to alcohol policy: An updated report from the provincial health ofcer. Victoria British Columbia: Ofce of the Provincial Health Ofcer.

Butt, P., Beirness, D., Cesa, F., Gliksman, L., Paradis, C., & Stockwell, T. (2011). Alcohol and health in Canada: A summary of evidence and guidelines for low-risk drinking. Ottawa, ON: Canadian Centre on Substance Abuse.

Canadian Public Health Association (CPHA). (2011). Too high a cost: A public health approach to alcohol policy in Canada. Ottawa: Canadian Public Health Association.

Cancer Care Ontario, & Ontario Agency for Health Protection and Promotion. (2012). Taking action to prevent chronic disease: Recommendations for a healthier Ontario. Toronto, Ontario: Queen's Printer for Ontario.

Giesbrecht, N., Stockwell, T., Kendall, P., Strang, R., & Thomas, G. (2011). Alcohol in Canada: Reducing the toll through focused interventions and public health policies Canadian Medical Association Journal, 183(4), 450-455. doi:doi:10.1503/cmaj.100825

Giesbrecht, N., Wettlaufer, A., April, N., Ashbridge, M., Cukier, S., Mann, R., & Vallance, K. (2013). Strategies to reduce alcohol-related harms and costs in Canada: A comparison of provincial policies. Toronto: Centre for Addiction and Mental Health.

Gordon, R., Hastings, G., & Moodie, C. (2010). Alcohol marketing and young people's drinking: What the evidence base suggests for policy. Journal of Public Affairs, 10(1/2), 88-101. doi:10.1002/pa.338

Heung, C., & Rempel, B. (2011). From evidence to action: Protecting children and youth from the harmful effects of alcohol advertising Ontario Public Health Association.

National Alcohol Strategy Working Group. (2007). Towards a culture of moderation, recommendations for a national alcohol strategy. (). Canada: Health Canada, Canadian Centre for Substance Abuse and Alberta Alcohol and Drug Abuse Commission.

National Institute for Health and Clinical Excellence. (2010). Alcohol use disorders: Preventing harmful drinking. Manchester, United Kingdom: National Institute for Health and Clinical Excellence.

Nova Scotia Department of Health and Wellness. (2012). Reducing alcohol harms among university students: A summary of best practices. (). Halifax, Nova Scotia: Province of Nova Scotia

Ontario Chronic Disease Prevention Alliance. (2010). Evidence-informed messages: High-risk alcohol consumption. Toronto, Canada: Ontario Chronic Disease Prevention Alliance.

Ontario Injury Prevention Resource Centre. (2008). Alcohol-related injury: Evidence-based practice synthesis document. Ontario: Queen's Printer for Ontario.

Public Health Agency of Canada. (2008). FASD prevention: Canadian perspectives. Canada: Public Health Agency of Canada.

The United Kingdom Home Ofce. (2011). The likely impacts of increasing alcohol price: A summary

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