Dr Emma Plugge

Research Area: Global Health
Scientific Themes: Tropical Medicine & Global Health

My two distinct areas of research interest are the health of socially excluded groups and educational research.

My previous research has examined the health of prisoners, drug users, commercial sex workers, probationers, those living in poverty and migrants. The current focus is on the health of prisoners across Europe and Central Asia, linking with the WHO Collaborating Centre for the Health in Prisons Programme, WHO European Region. Other strands of research include work on the prevention of Female Genital Mutilation (FGM) in affected communities in the UK through community researchers.

As a fellow of the Higher Education Academy, I retain a keen interest in educational issues, particularly interprofessional education and capacity building for health.

There are no collaborations listed for this principal investigator.

Plugge E, Stürup-Toft S, O'Moore ÉJ, Møller L. 2017. WEPHREN: a global prison health research network. Int J Prison Health, 13 (2), pp. 65-67. | Read more

Sutherland A, Naessens K, Plugge E, Head K, Burton MJ, Wee B. 2017. Olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults Cochrane Database of Systematic Reviews, 2017 (2), | Show Abstract | Read more

© 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the efficacy and safety of olanzapine when used as an anti-emetic in the prevention and treatment of nausea and vomiting related to cancer in adults.

Hong B, Plugge E. 2017. Critical appraisal skills teaching in UK dental schools British Dental Journal, 222 (3), pp. 209-213. | Show Abstract | Read more

© 2017 British Dental Association. All rights reserved. Key publications on training in dentistry, including the latest version of the General Dental Council learning outcomes for dentists, recognise the importance of teaching evidence-based practice for dental students. However, dental curriculum designers have considerable flexibility on the scope and approach for teaching evidence-based dentistry (EBD) and there is no readily available information showing how EBD is taught across the dental schools in the United Kingdom (UK). Critical appraisal is one of the key steps of evidence-based decision making and so we investigated through an electronic survey whether and how critical appraisal skills (CAS) are taught and assessed across the UK dental schools. The survey included questions regarding teaching methods, duration and timing of CAS teaching, and assessment methods. Twelve out of the total 16 UK dental schools participated in this survey, giving an institutional response rate of 75%. While all 12 participating UK dental schools reported CAS were taught and assessed in their institution, there were very varied approaches between institutions in every surveyed aspect of CAS education. CAS teaching and assessment strategies should be regularly reviewed in line with the evolving dental curriculum. Regular inter-And intra-institutional review of teaching, specifically in evidence-based dentistry including CAS may encourage professional debate regarding facilitation of improved CAS and their integration into clinical practice.

Hong B, Plugge E. 2017. Critical appraisal skills teaching in UK dental schools. Br Dent J, 222 (3), pp. 209-213. | Show Abstract | Read more

Key publications on training in dentistry, including the latest version of the General Dental Council learning outcomes for dentists, recognise the importance of teaching evidence-based practice for dental students. However, dental curriculum designers have considerable flexibility on the scope and approach for teaching evidence-based dentistry (EBD) and there is no readily available information showing how EBD is taught across the dental schools in the United Kingdom (UK). Critical appraisal is one of the key steps of evidence-based decision making and so we investigated through an electronic survey whether and how critical appraisal skills (CAS) are taught and assessed across the UK dental schools. The survey included questions regarding teaching methods, duration and timing of CAS teaching, and assessment methods. Twelve out of the total 16 UK dental schools participated in this survey, giving an institutional response rate of 75%. While all 12 participating UK dental schools reported CAS were taught and assessed in their institution, there were very varied approaches between institutions in every surveyed aspect of CAS education. CAS teaching and assessment strategies should be regularly reviewed in line with the evolving dental curriculum. Regular inter- and intra-institutional review of teaching, specifically in evidence-based dentistry including CAS may encourage professional debate regarding facilitation of improved CAS and their integration into clinical practice.

Bard E, Knight M, Plugge E. 2016. Perinatal health care services for imprisoned pregnant women and associated outcomes: a systematic review. BMC Pregnancy Childbirth, 16 (1), pp. 285. | Show Abstract | Read more

BACKGROUND: Women are an increasing minority of prisoners worldwide, and most are of childbearing age. Prisons offer unique opportunities for improving the pregnancy outcomes of these high-risk women, and no systematic review to date has looked at their care. This systematic review identified studies describing models of perinatal health care for imprisoned women which report maternal and child health and care outcomes. METHODS: We systematically searched for literature published between 1980 and April 2014. Studies were eligible if they included a group of imprisoned pregnant women, a description of perinatal health care and any maternal or infant health or care outcomes. Two authors independently extracted data. We described relevant outcomes in prisons (including jails) under models of care we termed PRISON, PRISON+ and PRISON++, depending on the care provided. Where outcomes were available on a comparison group of women, we calculated odds ratios with 95 % confidence intervals. RESULTS: Eighteen studies were reported, comprising 2001 imprisoned pregnant women. Fifteen were in the US, two in the UK and one in Germany. Nine contained a comparison group of women comprising 849 pregnant women. Study quality was variable and outcome reporting was inconsistent. There was some evidence that women in prisons receiving enhanced prison care, PRISON+, were less likely to have inadequate prenatal care (15.4 % vs 30.7 %, p < 0 · 001), preterm delivery (6.4 % vs 19.0 %, p = 0 · 001) or caesarean delivery (12.9 % vs 26.5 %, p = 0 · 005) compared to women in prisons receiving usual care (PRISON). Women participating in two PRISON++ interventions, that is, interventions which included not only enhanced care in prisons but also coordination of community care on release, demonstrated reductions in long term recidivism rates (summary OR 0 · 37, 95 % CI 0 · 19-0 · 70) compared to pregnant women in the same prisons who did not participate in the intervention. CONCLUSIONS: Enhanced perinatal care can improve both short and long-term outcomes but there is a lack of data. Properly designed programmes with rigorous evaluation are needed to address the needs of this vulnerable population. The cost to mothers, children and to society of failing to address these important public health issues are likely to be substantial. TRIAL REGISTRATION: PROSPERO registration: CRD42012002384 .

Rayfield S, Plugge E. 2017. Systematic review and meta-analysis of the association between maternal smoking in pregnancy and childhood overweight and obesity. J Epidemiol Community Health, 71 (2), pp. 162-173. | Show Abstract | Read more

BACKGROUND: By 2020, it is predicted that 60 million children worldwide will be overweight. Maternal smoking in pregnancy has been suggested as a contributing factor. Our objective was to systematically review studies on this, thereby expanding the evidence base for this association. METHODS: Systematic review with meta-analysis, Prospero Registration number CRD42012002859. We searched PubMed, Embase, Global Health, Web of Science and the Grey literature. We included prevalence, cohort and cross-sectional studies involving full-term, singleton pregnancies. Published and unpublished studies through to 1 January 2015 in all languages, demonstrating an objective overweight outcome up until 18 years of age and data presented as an OR, were included. Quality assessment was undertaken using an adaption of the Newcastle-Ottawa scale. Statistical analysis was performed using Review Manager V.5.3. FINDINGS: The meta-analysis included 39 studies of 236 687 children from Europe, Australia, North America and South America and Asia. Maternal smoking in pregnancy ranged from 5.5% to 38.7%, with the prevalence of overweight from 6.3% to 32.1% and obesity from 2.6% to 17%. Pooled adjusted ORs demonstrated an elevated odds of maternal smoking in pregnancy for childhood overweight (OR 1.37, 95% CI 1.28 to 1.46, I2 45%) and childhood obesity (OR 1.55, 95% CI 1.40 to 1.73, I2 24%). INTERPRETATION: Our results demonstrate an association between maternal prenatal smoking and childhood overweight. This contributes to the growing evidence for the aetiology of childhood overweight, providing important information for policymakers and health professionals alike in planning cessation programmes or antismoking interventions for pregnant female smokers.

Fellmeth G, Fazel M, Plugge E. 2017. Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis. BJOG, 124 (5), pp. 742-752. | Show Abstract | Read more

BACKGROUND: Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration. OBJECTIVES: This systematic review and meta-analysis summarises the prevalence, associated factors and interventions for perinatal mental disorders in migrant women from low- and middle-income countries (LMIC). SEARCH STRATEGY: We systematically searched nine electronic databases and the grey literature using a predefined search strategy. SELECTION CRITERIA: Studies were included if they assessed pregnant or postpartum migrants from LMIC, used a structured tool and a case-control, cross-sectional, cohort or intervention study design. DATA COLLECTION AND ANALYSIS: Data was double-extracted. We calculated pooled prevalence of depression and weighted mean anxiety and depression scores. We calculated crude odds ratios from risk factor studies and summarised intervention studies descriptively. MAIN RESULTS: Forty studies were identified from 10 123 references. Pooled prevalence was 31% [95% condidence interval (CI) 23%-40%] for any depressive disorder and 17% (95% CI 12-23%) for major depressive disorder. Previous depression and lower social support were associated with perinatal depression. There were insufficient data to assess the burden of anxiety, post-traumatic stress disorder or psychosis in this population. CONCLUSIONS: One in three migrant women from LMIC experiences symptoms of perinatal depression. Social support is an important protective factor. Evidence on LMIC women relocating to other LMIC is lacking. Given the adverse consequences of perinatal mental illness on women and their children, further research in low-resource settings is a priority. TWEETABLE ABSTRACT: One in three migrant women from low- and middle-income countries has symptoms of perinatal depression.

Preston EC, Ariana P, Penny ME, Frost M, Plugge E. 2015. Prevalence of childhood overweight and obesity and associated factors in Peru. Rev Panam Salud Publica, 38 (6), pp. 472-478. | Show Abstract

OBJECTIVE: To determine the prevalence of and factors associated with childhood overweight and obesity among a cohort of children 7-8 years of age in Peru. METHODS: This was a cross-sectional secondary analysis of data from the Young Lives longitudinal study of childhood poverty. The sample was a cohort of 1 737 children 7-8 years of age in 2009. Prevalence of overweight and obesity was assessed using body mass index-forage Z-scores. Logistic regression was used to determine associations with a number of individual, household, and community factors. RESULTS: Prevalences of overweight and obesity were 19.2% and 8.6%, respectively. A prevalence of 32.0% and 23.5% overweight and obesity was found among males and females, respectively. High socioeconomic status, living in Lima, having a mother who was overweight or obese, being male, and being an only child or having only one sibling were associated with being overweight and obese at this age. CONCLUSIONS: This study shows a high prevalence of childhood and maternal overweight and obesity in Peru. In contrast to findings in many high-income countries, the findings in Peru indicate that children from wealthier households were more likely to be overweight or obese than those from poorer households. In addition, there is something particularly obesogenic about the Lima environment that merits further investigation, and several key issues to consider when targeting future interventions and research.

Awoh AB, Plugge E. 2016. Immunisation coverage in rural-urban migrant children in low and middle-income countries (LMICs): a systematic review and meta-analysis. J Epidemiol Community Health, 70 (3), pp. 305-311. | Show Abstract | Read more

BACKGROUND: The majority of children who die from vaccine-preventable diseases (VPDs) live in low-income and-middle-income countries (LMICs). With the rapid urbanisation and rural-urban migration ongoing in LMICs, available research suggests that migration status might be a determinant of immunisation coverage in LMICs, with rural-urban migrant (RUM) children being less likely to be immunised. OBJECTIVES: To examine and synthesise the data on immunisation coverage in RUM children in LMICs and to compare coverage in these children with non-migrant children. METHODS: A multiple database search of published and unpublished literature on immunisation coverage for the routine Expanded Programme on Immunisation (EPI) vaccines in RUM children aged 5 years and below was conducted. Following a staged exclusion process, studies that met the inclusion criteria were assessed for quality and data extracted for meta-analysis. RESULTS: Eleven studies from three countries (China, India and Nigeria) were included in the review. There was substantial statistical heterogeneity between the studies, thus no summary estimate was reported for the meta-analysis. Data synthesis from the studies showed that the proportion of fully immunised RUM children was lower than the WHO bench-mark of 90% at the national level. RUMs were also less likely to be fully immunised than the urban-non-migrants and general population. For the individual EPI vaccines, all but two studies showed lower immunisation coverage in RUMs compared with the general population using national coverage estimates. CONCLUSIONS: This review indicates that there is an association between rural-urban migration and immunisation coverage in LMICs with RUMs being less likely to be fully immunised than the urban non-migrants and the general population. Specific efforts to improve immunisation coverage in this subpopulation of urban residents will not only reduce morbidity and mortality from VPDs in migrants but will also reduce health inequity and the risk of infectious disease outbreaks in wider society.

Fellmeth G, Plugge E, Paw MK, Charunwatthana P, Nosten F, McGready R. 2015. Pregnant migrant and refugee women's perceptions of mental illness on the Thai-Myanmar border: a qualitative study. BMC Pregnancy Childbirth, 15 (1), pp. 93. | Show Abstract | Read more

BACKGROUND: Mental illness is a significant contributor to the global burden of disease, with prevalence highest in low- and middle-income countries. Rates are high in women of childbearing age, especially during pregnancy and the first year post-partum. Migrant and refugee populations are at risk of developing mental illness due to the multiple stressors associated with migration. The Thai-Myanmar border area is home to large populations of migrants and refugees as a result of long-standing conflict, poverty and unemployment in Myanmar. This study aims to explore perceptions of mental illness among pregnant migrants and refugees and antenatal clinic staff living and working along the Thai-Myanmar border. METHODS: Thirteen focus group discussions were conducted with pregnant migrants, pregnant refugees and antenatal clinic staff. Focus groups were held in one large refugee camp and two migrant health clinics along the Thai-Myanmar border. Thematic analysis was used to identify and code themes emerging from the data. RESULTS: A total of 92 pregnant women and 24 antenatal clinic staff participated. Discussions centered around five main themes: symptoms of mental illness; causes of mental illness; suicide; mental illness during pregnancy and the post-partum period; and managing mental illness. Symptoms of mental illness included emotional disturbances, somatic symptoms and socially inappropriate behavior. The main causes were described as current economic and family-related difficulties. Suicide was frequently attributed to shame. Mental illness was thought to be more common during and following pregnancy due to a lack of family support and worries about the future. Talking to family and friends, medication and hospitalization were suggested as means of helping those suffering from mental illness. CONCLUSIONS: Mental illness was recognized as a concept by the majority of participants and there was a general willingness to discuss various aspects of it. More formal and systematic training including the development of assessment tools in the local languages would enable better ascertainment and treatment of mental illness in this population.

Turner K, Foster C, Allender S, Plugge E. 2015. A systematic review of how researchers characterize the school environment in determining its effect on student obesity. BMC Obes, 2 (1), pp. 13. | Show Abstract | Read more

BACKGROUND: Obesity in early childhood is a robust predictor of obesity later in life. Schools provide unparalleled access to children and have subsequently become major intervention sites. However, empirical evidence supporting the effectiveness of school-based interventions against childhood obesity is of limited scope and unknown quality. The aim of this systematic review is to critically assess how researchers have characterized the school environment in determining its effect on childhood weight status in order to improve the quality and consistency of research in this area. We conducted a narrative review with a systematic search of the literature in line with PRISMA guidelines (2009). Original peer-reviewed research articles in English were searched from Medline, EMBASE, CENTRAL, CINAHL and PsycINFO databases from earliest record to January 2014. We included empirical research that reported at least one measure of the primary/elementary school environment and its relationship with at least one objective adiposity-related variable for students aged 4-12 years. Two authors independently extracted data on study design, school-level factors, student weight status, type of analysis and effect. RESULTS: Five studies met the inclusion criteria. Each study targeted different parts of the school environment and findings across the studies were not comparable. The instruments used to collect school-level data report no validity or reliability testing. CONCLUSIONS: Our review shows that researchers have used instruments of unknown quality to test if the school environment is a determinant of childhood obesity, which raises broader questions about the impact that schools can play in obesity prevention.

Plugge E, Ahmed Abdul Pari A, Maxwell J, Holland S. 2014. When prison is "easier": probationers' perceptions of health and wellbeing. Int J Prison Health, 10 (1), pp. 38-46. | Show Abstract | Read more

PURPOSE: There are currently over 300,000 offenders in England and Wales and the majority, around 240,000, are in the community on probation. However, there is a paucity of research on their health and healthcare needs. The purpose of this paper is to explore issues around health and access to health services for those on probation. In particular the paper explores what people on probation consider to be the key health issues currently affecting them, and to identify barriers to accessing healthcare in the community. DESIGN/METHODOLOGY/APPROACH: The authors ran six focus groups with a total of 41 participants; two were with staff and the others with men and women on probation. In each focus group, the researchers used semi-structured guide and the discussions were recorded electronically and then transcribed. The paper adopted a thematic analytical framework and used NVivo 7 to facilitate analysis. FINDINGS: Both probationers and professionals largely agreed about the key issues which included substance use and mental health problems. However, the most important issue for probationers was dealing with the stress of being on probation which was not generally recognised by professionals. All participants recognised the impact of issues such as housing, finances and employment on the wellbeing of probationers and were concerned about the lack of access to health services, in particular mental health and alcohol services. RESEARCH LIMITATIONS/IMPLICATIONS: This was a small study conducted in one part of England and therefore it is not clear that the findings are generalisable. However, it raises important issues about the mental health needs of probationers and the lack of appropriate services for them. Effective services may have positive impact on re-offending and further research is needed to evaluate models of care. PRACTICAL IMPLICATIONS: The challenge remains for local health service commissioners and providers and the probation service to work together to provide appropriate and accessible services for all those on probation. ORIGINALITY/VALUE: Nearly one-quarter of a million people are on probation at any one time in the UK but the existing evidence on their health is patchy and dated. Little is known about effective health interventions or the extent to which their health needs are met. This study shows that probationers see the stress of being on probation as their most important health concern. Both probationers and staff recognise that mental health and substance use are persistent problems and that these important health needs in these areas are not being met by existing services.

McLaren E, Baugh V, Plugge E, O'Moore E. 2013. Describing the burden of infectious diseases among a population of detainees in an immigration removal centre (IRC) in the United Kingdom: A descriptive epidemiological approach Journal of Immigrant and Minority Health, 15 (4), pp. 764-770. | Show Abstract | Read more

This study aimed to describe the burden of infectious disease within one immigration removal centre (IRC) in southern England using available data. We conducted a review of existing databases used to record cases of infectious disease and extracted health information from a random sample of 50 % of detainee medical notes. We found that there was poor correlation between routine databases and that no systematic infectious disease screening is undertaken within the IRC. However, infectious diseases were an important public health issue in the IRC: 2 % of detainees were recorded as being hepatitis B virus positive, 1 % were HIV positive, and 3 % had a diagnosis of Tuberculosis. This study's quantification of the burden of infectious diseases relies upon self-disclosure and therefore underestimates true prevalence. Consideration should be given to screening for infectious diseases in the IRC. Where disease is identified, systems for case-tracking are poorly aligned between services. © 2012 Springer Science+Business Media, LLC.

Cole DC, Plugge EH, Jackson SF. 2013. Placements in global health masters' programmes: what is the student experience? J Public Health (Oxf), 35 (2), pp. 329-337. | Show Abstract | Read more

BACKGROUND: Global health training is increasingly part of public health training in high-income countries, with placements as key components. We sought preliminary evidence of student placement experiences and learning through masters' programmes at the universities of Oxford and Toronto. METHODS: In a mixed-methods design, we drew on existing programme records, student feedback surveys (Oxford only) and semi-structured interviews with graduates. RESULTS: Students participated in practice, informed policy and conducted research across a wide variety of topics, and with a range of different tasks, mostly overseas. Building on existing collaboration- or partnership-facilitated placement setup. Clear communication and face-to-face time with organizational representatives or on-site supervisors helped clarify placement objectives. Flexibility on students' and supervisors' part enabled students to take advantage of urgent public health activities for learning. Students valued the opportunity to make cross-country comparisons, to see first-hand the role of international organizations and to learn concrete skills in project design, questionnaire formulation, qualitative and quantitative analysis and writing up. CONCLUSIONS: Placements were valuable to public health professionals in training. We encourage other programmes to share placement experience of their students, field supervisors and host organizations.

Herbert K, Plugge E, Foster C, Doll H. 2012. Risk factors for non-communicable diseases in prison populations Reply LANCET, 380 (9849), pp. 1227-1228. | Read more

Barnett I, Ariana P, Petrou S, Penny ME, Duc LT, Galab S, Woldehanna T, Escobal JA, Plugge E, Boyden J. 2013. Cohort profile: the Young Lives study. Int J Epidemiol, 42 (3), pp. 701-708. | Show Abstract | Read more

Young Lives is an international longitudinal study investigating the changing nature of childhood poverty in four low-income countries [Ethiopia, India (Andhra Pradesh), Peru and Vietnam] over a 15-year period. In each country, the cohort is comprised of ≈ 2000 children aged between 6 and 18 months and up to 1000 children aged between 7 and 8 years, recruited in 2002 and sampled from 20 sentinel sites. The first survey data collection from primary caregivers and older children took place in 2002, the second in 2006-07 and the third in 2009-10. Data on the community contexts were collected to complement the household surveys. To elaborate and extend the quantitative data, longitudinal qualitative research with a subgroup of the children was carried out in 2007, 2008 and 2010-11. Topic areas covered included nutrition, health and well-being, cognitive and physical development, health behaviours and education, as well as the social, demographic and economic status of the household. Survey data from the study are archived in the International Section of the UK Public Data Archive.

Fischer J, Butt C, Dawes H, Foster C, Neale J, Plugge E, Wheeler C, Wright N. 2012. Fitness levels and physical activity among class A drug users entering prison. Br J Sports Med, 46 (16), pp. 1142-1144. | Show Abstract | Read more

BACKGROUND: Physical activity could benefit drug users' physiological and mental health. Previous research has suggested that physical activity levels change when drug users enter prison. METHODS: Twenty-five class A drug users who were new to prison answered physical activity and drug use cross-sectional questionnaires, took a submaximal fitness test and wore a pedometer for 1 week. RESULTS: Participants' mean aerobic capacity was estimated as 49 mls O2/kg/min (±12 SD). Their mean self-reported walking distance outside of prison was 4.67 miles on an average day (±4.14 SD). Pedometer data suggest they walked a mean of 1.8 miles/day in prison. CONCLUSION: Many class A drug users entering prison had high levels of fitness and physical activity before admission, often gained from walking. Walking activity reduced when they entered prison, posing a challenge to maintaining healthy activity levels.

Herbert K, Plugge E, Foster C, Doll H. 2012. Prevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review. Lancet, 379 (9830), pp. 1975-1982. | Show Abstract | Read more

BACKGROUND: The burden of non-communicable diseases (NCDs) is disproportionately carried by low-income and middle-income countries and disadvantaged sectors of society such as prisoners. No systematic analysis has been done to assess the prevalence of poor diet, inadequate physical activity, and overweight and obesity in prisoners. We aim to synthesise current evidence and to highlight areas for action and further research. METHODS: We systematically searched online databases for reports published between 1948 and May, 2011. Studies were screened against eligibility criteria; two authors then independently extracted data with previously agreed proformas. The risk of bias was assessed for each study with a domain-based assessment. Data on body-mass index and physical activity were presented in forest plots; no overall estimates were calculated on account of data heterogeneity. Available data from the population subgroup most similar in terms of age and sex were used to calculate age-adjusted and sex-adjusted prevalence ratios, which estimate the likelihood of insufficient activity and obesity prevalence in prisoners compared with the national population. FINDINGS: 31 eligible studies were reported in 29 publications, including more than 60,000 prisoners in 884 institutions in 15 countries. Male prisoners were less likely to be obese than males in the general population (prevalence ratios ranged from 0·33 to 0·87) in all but one study (1·02, 0·92-1·07), whereas female prisoners were more likely to be obese than non-imprisoned women in the USA (1·18, 1·08-1·30) and Australia (prevalence ratios ranged from 1·15 to 1·20). Australian prisoners were more likely to achieve sufficient activity levels than the general population compared with prisoners in the UK (prevalence ratio 1·19, 95% CI 1·04-1·37, for women in Australia in 2009 vs 0·32, 0·21-0·47, for women in the UK; prevalence ratios ranged from 1·37 to 1·59 for men in Australia vs 0·71, 0·34-0·78, for men in the UK). Female mean energy intake exceeded recommended levels and sodium intake was about two to three times the recommended intake for all prisoners. INTERPRETATION: Contact with the criminal justice system is a public-health opportunity to promote health in this vulnerable population; the costs to the individual and to society of failing to do so are likely to be substantial. Improved monitoring and further research is essential to inform appropriate targeting of public health interventions. FUNDING: Oxford University Department of Public Health, Oxford University Hospitals NHS Trust.

Herbert K, Plugge E, Foster C, Doll H. 2012. Authors' reply The Lancet, 380 (9849), pp. 1227-1228.

Fischer J, Butt C, Dawes H, Foster C, Neale J, Plugge E, Wheeler C, Wright N. 2012. Fitness levels and physical activity among class A drug users entering prison British Journal of Sports Medicine, 46 (16), pp. 1142-1144. | Show Abstract | Read more

Physical activity could benefit drug users' physiological and mental health. Previous research has suggested that physical activity levels change when drug users enter prison. Methods Twenty-five class A drug users who were new to prison answered physical activity and drug use cross-sectional questionnaires, took a submaximal fitness test and wore a pedometer for 1 week. Results Participants' mean aerobic capacity was estimated as 49 mls O 2 /kg/min (±12 SD). Their mean selfreported walking distance outside of prison was 4.67 miles on an average day (±4.14 SD). Pedometer data suggest they walked a mean of 1.8 miles/day in prison. Conclusion Many class A drug users entering prison had high levels of fitness and physical activity before admission, often gained from walking. Walking activity reduced when they entered prison, posing a challenge to maintaining healthy activity levels.

Cited:

48

Scopus

Herbert K, Plugge E, Foster C, Doll H. 2012. Prevalence of risk factors for non-communicable diseases in prison populations worldwide: A systematic review The Lancet, 379 (9830), pp. 1975-1982. | Show Abstract | Read more

The burden of non-communicable diseases (NCDs) is disproportionately carried by low-income and middle-income countries and disadvantaged sectors of society such as prisoners. No systematic analysis has been done to assess the prevalence of poor diet, inadequate physical activity, and overweight and obesity in prisoners. We aim to synthesise current evidence and to highlight areas for action and further research. Methods We systematically searched online databases for reports published between 1948 and May, 2011. Studies were screened against eligibility criteria; two authors then independently extracted data with previously agreed proformas. The risk of bias was assessed for each study with a domain-based assessment. Data on body-mass index and physical activity were presented in forest plots; no overall estimates were calculated on account of data heterogeneity. Available data from the population subgroup most similar in terms of age and sex were used to calculate age-adjusted and sex-adjusted prevalence ratios, which estimate the likelihood of insuffi cient activity and obesity prevalence in prisoners compared with the national population. Findings 31 eligible studies were reported in 29 publications, including more than 60 000 prisoners in 884 institutions in 15 countries. Male prisoners were less likely to be obese than males in the general population (prevalence ratios ranged from 0·33 to 0·87) in all but one study (1·02, 0·92-1·07), whereas female prisoners were more likely to be obese than non-imprisoned women in the USA (1·18, 1·08-1·30) and Australia (prevalence ratios ranged from 1·15 to 1·20). Australian prisoners were more likely to achieve suffi cient activity levels than the general population compared with prisoners in the UK (prevalence ratio 1·19, 95% CI 1·04-1·37, for women in Australia in 2009 vs 0·32, 0·21-0·47, for women in the UK; prevalence ratios ranged from 1·37 to 1·59 for men in Australia vs 0·71, 0·34-0·78, for men in the UK). Female mean energy intake exceeded recommended levels and sodium intake was about t wo to three times the recommended intake for all prisoners. Interpretation Contact with the criminal justice system is a public-health opportunity to promote health in this vulnerable population; the costs to the individual and to society of failing to do so are likely to be substantial. Improved monitoring and further research is essential to inform appropriate targeting of public health interventions.

McLaren E, Baugh V, Plugge E, O'Moore É. 2013. Describing the burden of infectious diseases among a population of detainees in an immigration removal centre (IRC) in the United Kingdom: a descriptive epidemiological approach. J Immigr Minor Health, 15 (4), pp. 764-770. | Show Abstract | Read more

This study aimed to describe the burden of infectious disease within one immigration removal centre (IRC) in southern England using available data. We conducted a review of existing databases used to record cases of infectious disease and extracted health information from a random sample of 50 % of detainee medical notes. We found that there was poor correlation between routine databases and that no systematic infectious disease screening is undertaken within the IRC. However, infectious diseases were an important public health issue in the IRC: 2 % of detainees were recorded as being hepatitis B virus positive, 1 % were HIV positive, and 3 % had a diagnosis of Tuberculosis. This study's quantification of the burden of infectious diseases relies upon self-disclosure and therefore underestimates true prevalence. Consideration should be given to screening for infectious diseases in the IRC. Where disease is identified, systems for case-tracking are poorly aligned between services.

McHardy K, Ariana P, Plugge E. 2011. Public Health in Practice: translating theory into action. Med Educ, 45 (11), pp. 1142. | Read more

Canavati S, Plugge E, Suwanjatuporn S, Sombatrungjaroen S, Nosten F. 2011. Barriers to immunization among children of migrant workers from Myanmar living in Tak province, Thailand. Bull World Health Organ, 89 (7), pp. 528-531. | Show Abstract | Read more

PROBLEM: Immunization is a cost-effective means of improving child survival but implementation of programmes in low- and middle-income countries is variable. Children of migrants are less likely to be immunized. APPROACH: The qualitative study aimed to identify barriers to the successful implementation of migrant immunization programmes in Tak province, Thailand. We ran a total of 53 focus groups involving 371 participants in three sites. LOCAL SETTING: Tak province in Thailand borders Myanmar and has an estimated 200,000 migrants from Myanmar. Vaccine-preventable diseases are a documented cause of morbidity in this population but there is no systematic or coordinated immunization programme in the area. RELEVANT CHANGES: As a result of the findings, the subsequent immunization campaign targeted children in school to overcome those barriers of distance to immunization services, fear of arrest, not remembering immunization appointments, and the disruption of parental work. The campaigns also included immunization education for both parents and teachers. LESSONS LEARNT: Migrant parents identified similar barriers to accessing childhood immunization programmes as migrant populations elsewhere in the world, although a unique barrier identified by parents from Myanmar was "fear of arrest". The subsequent school-based strategy to overcome these barriers appears to be effective.

Shah S, Plugge EH, Douglas N. 2011. Ethnic differences in the health of women prisoners. Public Health, 125 (6), pp. 349-356. | Show Abstract | Read more

OBJECTIVES: The numbers of female and ethnic minority prisoners in the UK are increasing. Despite recent policy initiatives to improve both prison healthcare and the status of women and ethnic minority groups, there are few data with which to inform service development. This is the first study in the UK to examine differences in subjective health status and health behaviours between Black and White female prisoners. STUDY DESIGN: Retrospective secondary analysis of data from the Health of Women in Prison Study by the University of Oxford. The latter was a longitudinal survey. METHODS: Participants were given a questionnaire containing the Short Form 36 (SF-36) and questions about cigarette smoking, alcohol consumption, illicit drug use, physical exercise, diet, imprisonment history and ethnicity. Data from Black and White participants were compared. Physical and mental component summary scores from the SF-36 were assessed using the independent t-test for means. Differences in health behaviours between the Black and White women were assessed using a paired samples t-test for continuous variables or Chi-squared test for categorical data. RESULTS: Black women were more likely to have stayed in full-time education for longer and to have been legally employed prior to imprisonment. The average length of their current sentence was significantly higher than that for White women. Black women scored higher in general health perception, but there were no other significant differences in subjective health status. Significantly fewer Black women smoked or drank to excess, or had used drugs in the 6 months prior to imprisonment. Black women ate more healthily, but were more likely to be overweight and to have higher blood pressure than their White counterparts. Both groups, however, demonstrated poor health and health behaviours overall. CONCLUSION: Black women entering prison are more likely to be educated, employed, drug free and, in some ways, healthier than White women. However, all the prisoners, regardless of ethnicity, had poorer levels of mental and physical health than the general population; thus, a need exists for researchers and policy makers alike to examine the health of these groups within and out of prison.

Canavati S, Plugge E, Suwanjatuporn S, Sombatrungjaroen S, Nostenc F. 2011. Barriers to immunization among children of migrant workers from myanmar living in tak province, Thailand Bulletin of the World Health Organization, 89 (7), pp. 528-531. | Show Abstract | Read more

Problem Immunization is a cost-effective means of improving child survival but implementation of programmes in low- and middleincome countries is variable. Children of migrants are less likely to be immunized. Approach The qualitative study aimed to identify barriers to the successful implementation of migrant immunization programmes in Tak province, Thailand. We ran a total of 53 focus groups involving 371 participants in three sites. Local setting Tak province in Thailand borders Myanmar and has an estimated 200 000 migrants from Myanmar. Vaccine-preventable diseases are a documented cause of morbidity in this population but there is no systematic or coordinated immunization programme in the area. Relevant changes As a result of the findings, the subsequent immunization campaign targeted children in school to overcome those barriers of distance to immunization services, fear of arrest, not remembering immunization appointments, and the disruption of parental work. The campaigns also included immunization education for both parents and teachers. Lessons learnt Migrant parents identified similar barriers to accessing childhood immunization programmes as migrant populations elsewhere in the world, although a unique barrier identified by parents from Myanmar was 'fear of arrest'. The subsequent schoolbased strategy to overcome these barriers appears to be effective.

Plugge E, Cole D. 2011. Oxford graduates' perceptions of a global health master's degree: a case study. Hum Resour Health, 9 (1), pp. 26. | Show Abstract | Read more

INTRODUCTION: Low and middle-income countries suffer an ongoing deficit of trained public health workers, yet optimizing postgraduate education to best address these training needs remains a challenge. Much international public health education literature has focused on global capacity building and/or the description of innovative programmes, but less on quality and appropriateness. CASE DESCRIPTION: The MSc in Global Health Science at the University of Oxford is a relatively new, full-time one year master's degree in international public health. The programme is intended for individuals with significant evidence of commitment to health in low and middle income countries. The intake is small, with only about 25 students each year, but they are from diverse professional and geographical backgrounds. Given the diversity of their backgrounds, we wanted to determine the extent to which student background influenced their perceptions of the quality of their learning experience and their learning outcomes. We conducted virtual or face-to-face semi-structured individual interviews with students who had graduated from the course at least one year previously. Of the 2005 to 2007 intake years, 52 of 63 graduates (83%) were interviewed. We used thematic analysis to analyze the data, then linked results to student characteristics. DISCUSSION: The findings from the evaluation suggested that all MSc GHS graduates who spoke with us, irrespective of background, appreciated the curriculum structure drawing on the strengths of a small, diverse student group, and the contribution the programme had made to their breadth of understanding and their careers. This evaluation also demonstrated the feasibility of an educational evaluation conducted several years after programme completion and when graduates were 'in the field'. This is important in ensuring international public health programmes are relevant to the day-to-day work of public health practitioners and researchers in low and middle-income countries. CONCLUSIONS: Feedback from students, when they had either resumed their positions 'in the field' or pursued further training, was useful in identifying valuable and positive aspects of the programme and also in identifying areas for further action and development by the programme's management and by individual teaching staff.

McHardy K, Ariana P, Plugge E. 2011. Public Health in Practice: translating theory into action. Medical education, 45 (11), pp. 1142.

Plugge E, Douglas N, Fitzpatrick R. 2011. Changes in health-related quality of life following imprisonment in 92 women in England: a three month follow-up study. Int J Equity Health, 10 (1), pp. 21. | Show Abstract | Read more

BACKGROUND: Despite the considerable changes in the provision of health care to prisoners in the UK there is little published literature that attempts to examine broader aspects of health and the impact of imprisonment on these, focusing instead on disease specific areas. This is surprising given that one of the main drivers behind the changes was the need for improvements in the quality of care; examining changes in health outcomes should be an important part of monitoring service developments. This study assessed the health-related quality of life of women on entry into prison and examined changes during a period of three months imprisonment. METHODS: This was a prospective longitudinal study involving 505 women prisoners in England. The SF-36 was contained within a questionnaire designed to examine many aspects of imprisoned women's health. Participants completed this questionnaire within 72 hours of entering prison. The researchers followed up all participants who were still imprisoned three months later. RESULTS: The study achieved good response rates: 82% of women agreed to participate initially (n = 505), and 93% of those still imprisoned participating three months later (n = 112). At prison entry, women prisoners have lower mental component summary score (MCS) and physical component summary score (PCS) compared to women within the general population. The mental well-being of those 112 women still imprisoned after three months improved over this period of imprisonment, although remained poorer than that of the general population. The PCS did not improve significantly and remained significantly lower than that of the general population. Multivariate analyses showed that the only independent predictor of change in component score was the score at baseline. CONCLUSIONS: The results highlight the poor health-related quality of life of women prisoners and highlight the scale of the challenge faced by those providing health care to prisoners. They also draw attention to the major health disadvantages of women offenders compared to women in general. While recent reforms may improve health services for prisoners, broader inequalities in the health of women are a more complex challenge.

Shah S, Plugge EH, Douglas N. 2011. Ethnic differences in the health of women prisoners Public Health, 125 (6), pp. 349-356. | Show Abstract | Read more

Objectives: The numbers of female and ethnic minority prisoners in the UK are increasing. Despite recent policy initiatives to improve both prison healthcare and the status of women and ethnic minority groups, there are few data with which to inform service development. This is the first study in the UK to examine differences in subjective health status and health behaviours between Black and White female prisoners. Study design: Retrospective secondary analysis of data from the Health of Women in Prison Study by the University of Oxford. The latter was a longitudinal survey. Methods: Participants were given a questionnaire containing the Short Form 36 (SF-36) and questions about cigarette smoking, alcohol consumption, illicit drug use, physical exercise, diet, imprisonment history and ethnicity. Data from Black and White participants were compared. Physical and mental component summary scores from the SF-36 were assessed using the independent t-test for means. Differences in health behaviours between the Black and White women were assessed using a paired samples t-test for continuous variables or Chi-squared test for categorical data. Results: Black women were more likely to have stayed in full-time education for longer and to have been legally employed prior to imprisonment. The average length of their current sentence was significantly higher than that for White women. Black women scored higher in general health perception, but there were no other significant differences in subjective health status. Significantly fewer Black women smoked or drank to excess, or had used drugs in the 6 months prior to imprisonment. Black women ate more healthily, but were more likely to be overweight and to have higher blood pressure than their White counterparts. Both groups, however, demonstrated poor health and health behaviours overall. Conclusion: Black women entering prison are more likely to be educated, employed, drug free and, in some ways, healthier than White women. However, all the prisoners, regardless of ethnicity, had poorer levels of mental and physical health than the general population; thus, a need exists for researchers and policy makers alike to examine the health of these groups within and out of prison. © 2011 The Royal Society for Public Health.

Mwangome M, Prentice A, Plugge E, Nweneka C. 2010. Determinants of appropriate child health and nutrition practices among women in rural Gambia. J Health Popul Nutr, 28 (2), pp. 167-172. | Show Abstract | Read more

Health education and awareness involves providing knowledge about causes of illness and choices to promote a change in individual behaviour and, thus, improves survival of individuals. Studies have, however, shown that improved knowledge and awareness is not always translated into appropriate actions. This study aimed at exploring the factors determining mothers' choices of appropriate child health and nutrition practices in the Gambia. Eight focus-group discussions (FGDs) were held with 63 women whose children had been seen at the Keneba MRC Clinic within the 12 months preceding the study. The FGDs were analyzed using a thematic framework. Gender inequality, presence or absence of support networks, alternative explanatory models of malnutrition, and poverty were identified as the main factors that would determine the ability of a mother to practise what she knows about child health and nutrition. The findings highlight the need to consider the broader social, cultural and economic factors, including the value of involving men in childcare, when designing nutritional interventions.

Plugge EH, Foster CE, Yudkin PL, Douglas N. 2009. Cardiovascular disease risk factors and women prisoners in the UK: the impact of imprisonment. Health Promot Int, 24 (4), pp. 334-343. | Show Abstract | Read more

Cardiovascular disease (CVD) is a leading cause of death throughout the world. In high income countries, the greatest burden of disease is seen in those from lower socio-economic groups. It is therefore likely that CVD is an important issue for prisoners in the UK, the majority of whom were either unemployed or in non-skilled employment prior to imprisonment. However, there is little research examining this issue. The aim of this study was to examine the prevalence of five modifiable cardiovascular risk factors (smoking, physical activity, diet, body mass index and hypertension) in women prisoners on entry to prison and then 1 month after imprisonment. This was a prospective longitudinal study involving 505 women prisoners in England. Participants completed a questionnaire containing questions about health-related behaviours within 72 h of entering prison. The researchers measured their blood pressure, height and weight. They followed up all participants who were still imprisoned 1 month later and invited them to participate again. The results showed that women prisoners were at high risk of CVD in the future; 85% smoked cigarettes, 87% were insufficiently active to benefit their health, 86% did not eat at least five portions of fruit and vegetables each day and 30% were overweight or obese. After 1 month, there were few improvements in risk factors. This may in part reflect the fact that, unlike prisons in other high income countries, there are currently no systematic approaches which address these health issues within UK women's prisons.

Douglas N, Plugge E, Fitzpatrick R. 2009. The impact of imprisonment on health: what do women prisoners say? J Epidemiol Community Health, 63 (9), pp. 749-754. | Show Abstract | Read more

BACKGROUND: Women prisoners tend to suffer poor health on a range of indicators. This study sought to explore women prisoners' perceptions of the impact of imprisonment on their health. METHODS: This qualitative study involved adult women prisoners in two closed local prisons. Focus groups and individual interviews were conducted. RESULTS: Women prisoners reported that imprisonment impacted negatively upon their health. The initial shock of imprisonment, separation from families and enforced living with other women suffering drug withdrawal and serious mental health problems affected their own mental health. Over the longer term, women complained of detention in unhygienic facilities by regimes that operated to disempower them, including in the management of their own health. Women described responses to imprisonment that were also health negating such as increased smoking, eating poorly and seeking psychotropic medication. However, imprisonment could also offer a respite from lives characterised by poverty, social exclusion, substance misuse and violence, with perceived improvements in health. CONCLUSION: The impact of imprisonment on women's health was mixed but was largely perceived to be negative. Despite policy initiatives to introduce health promotion in prisons, there is little evidence of the extent to which this has been effective. The current policy climate in the UK makes it especially timely to examine the reported experience of women prisoners themselves about the impact of imprisonment on their health and to re-evaluate health promotion in women's prisons.

Plugge E, Yudkin P, Douglas N. 2009. Changes in women's use of illicit drugs following imprisonment. Addiction, 104 (2), pp. 215-222. | Show Abstract | Read more

AIM: To provide data on changes in illegal drug use in women following imprisonment. DESIGN: Prospective cohort study. SETTING: Recruitment took place in two prisons in the Midlands and South-East England and follow-up in 13 prisons across England. PARTICIPANTS: A total of 505 women prisoners participated, a response rate of 82%. Measurements Questions about drug use were contained within a questionnaire which examined broad aspects of health. On entry into prison, women answered questions about daily drug use and injecting drug use prior to imprisonment. One month later the questionnaires examined drug use during this period of imprisonment. FINDINGS: Prior to imprisonment, 53% [95% confidence interval (CI): 49-58%] of women took at least one illegal drug daily and 38% (CI: 34-42%) said they had ever injected drugs. Following imprisonment, some women continued to use drugs; 14% (CI: 10-20%) of women reported using at least one illegal drug daily and 2% (CI: 0.7-5%) of women had injected drugs. There were important changes in the types of drugs used; there was a change in use from crack and heroin to benzodiazepines and opiate substitutes. Prior to imprisonment, women most commonly used crack and heroin, but in prison the two most commonly used illegal drugs were benzodiazepines and opiate substitutes. CONCLUSIONS: The study provides quantitative evidence of the impact of imprisonment on drug use among women. It highlights the need for enhanced drug treatment services and stronger measures to reduce the availability of illegal drugs to women in prison.

Chambers JC, Yiend J, Barrett B, Burns T, Doll H, Fazel S, Jenkinson C, Kaur A, Knapp M, Plugge E et al. 2009. Outcome measures used in forensic mental health research: a structured review. Crim Behav Ment Health, 19 (1), pp. 9-27. | Show Abstract | Read more

BACKGROUND: The evidence base for forensic mental health (FMH) services has been developing since the late 1990s. Are outcome measures sound enough for the evaluation tasks? AIMS: To identify, from published literature, outcome measures used in FMH research and, where feasible, assess their quality. METHOD: A structured review was undertaken of trials and intervention studies published between 1990 and 2006. Details of outcome variables and measures were abstracted. Evidence regarding most frequently occurring outcome measures was assessed. RESULTS: Four hundred and fifty different instruments were used to assess outcomes, incorporating 1038 distinct variables. Very little evidence could be found to support the measurement properties of commonly used instruments. CONCLUSIONS: and implications for practice There is little consistency in the use of outcome measure in FMH research. Effort is required to reach consensus on validated outcome measures in this field in order to better inform practice.

Plugge E, Douglas N, Fitzpatrick R. 2008. Imprisoned women's concepts of health and illness: the implications for policy on patient and public involvement in healthcare. J Public Health Policy, 29 (4), pp. 424-439. | Show Abstract | Read more

In the United Kingdom (UK), government policy urges involvement of patients in their care and in health-related research. Women prisoners have considerable health needs and constitute an important "patient" group. This study explores women prisoners' perceptions of health and illness to consider the extent to which they differed from those of lay people. Thirty-seven women participated in six focus groups across two prisons in England. They spoke about their views of health and what it was to be healthy. Women prisoners' concepts of health and well-being were similar to those of lay people and they demonstrated a good understanding of the key health issues faced by women prisoners. This group have much to contribute to the research process and researchers should attempt to overcome the existing barriers in order to involve prisoners more fully in line with UK Government policy.

Plugge E, Douglas N, Fitzpatrick R. 2008. Patients, prisoners, or people? Women prisoners' experiences of primary care in prison: a qualitative study. Br J Gen Pract, 58 (554), pp. 630-636. | Show Abstract | Read more

BACKGROUND: The development of primary care services within prisons has been central to improvements in the provision of health care in this setting over the past decade. Despite national imperatives to involve patients in the development of services and numerous policy initiatives, there has been no systematic evaluation of changes in the delivery of primary care and little published evidence of consultation with prisoners. AIM: To explore women prisoners' experiences of primary healthcare provision in prison. DESIGN OF STUDY: Qualitative study using focus groups and interviews. SETTING: Two women's prisons in southern England. METHOD: Six focus groups involving 37 women were conducted, as well as 12 semi-structured individual interviews. Focus groups and interviews were recorded, transcribed, and analysed thematically. RESULTS: Women prisoners' perceptions of the quality of prison health care were mixed. There were accounts of good-quality care where practitioners were regarded as knowledgeable and respectful, but many perceived that the quality of care was poor. They complained about difficulties accessing care or medication, disrespectful treatment, and breaches of confidentiality by practitioners. They voiced the belief that staff were less qualified and competent than their counterparts in the community. CONCLUSION: The prison environment presents unique challenges to those providing health care, and much work has been done recently on modernizing prison health care and improving professional standards of practice. However, the accounts of women prisoners in this study suggest that there is a gap between patient experience and policy aspirations.

Douglas N, Plugge E. 2008. The health needs of imprisoned female juvenile offenders: the views of the young women prisoners and youth justice professionals. Int J Prison Health, 4 (2), pp. 66-76. | Show Abstract | Read more

Little is known about the health needs of detained juvenile females, yet there is emerging concern regarding substance misuse, mental health problems, poor sexual health and poorer general physical health on a range of indicators. This study sought to identify health needs from the perspective of imprisoned young women themselves and key professionals working with them to inform healthcare provision. We conducted semi-structured interviews and focus groups with detained juvenile women and adult professionals in four specialist female young offender institutions. The study presents new qualitative findings on the profound impact of social exclusion and multiple forms of abuse and victimisation on the health of juvenile women prisoners. Concerns regarding substance misuse, mental health problems, self-harm and poor sexual health are reinforced by this study. Young women tended to focus on their immediate health needs in contrast to the professionals who emphasised longer-term issues. The study identified the need for priority interventions in relation to mental health, substance misuse, self-harm and sexual health and tentatively suggests that 'compensatory care' may offer some scope to redress health inequalities experienced by these young women.

Plugge EH, Yudkin PL, Douglas N. 2007. Predictors of hepatitis B vaccination in women prisoners in two prisons in England. J Public Health (Oxf), 29 (4), pp. 429-433. | Show Abstract | Read more

BACKGROUND: Hepatitis B is an important public health issue, especially in the female prison population. The high prevalence in this population is largely accounted for by the high rates of injecting drug use and the fact that these women are more likely to exchange sex for drugs or money and practice unprotected sex. There is a national programme in English prisons to vaccinate everyone against Hepatitis B. This study aimed to investigate whether women who had been in prison before were more likely to have been vaccinated against hepatitis B and whether contact with community services was more likely to predict hepatitis B vaccination. METHODS: A questionnaire survey of new entrants into two women's prisons in England. RESULTS: Four hundred and eighty seven out of 613 women approached completed the questionnaire and gave complete data on hepatitis B vaccination status, giving a response rate of 79.4%. One hundred and thirty three women (27.3%) had received at least three vaccinations against hepatitis B. Previous imprisonment and intravenous drug use were independent predictors of vaccination. Six months or more in prison greatly increased an individual's odds of being immunized [odds ratio 12.01 (95% confidence interval (CI) 5.53-26.10)]. Registration with a general practitioner (GP), contact with drug or alcohol services and exchanging money or goods for sex were not independently associated with vaccination status. CONCLUSION: Prisons play an important role in the delivery of hepatitis B vaccination. However, this should not prevent providers of health services making greater efforts to engage this marginalized group and to ensure that they receive an appropriate level of healthcare in the community.

Rayfield S, Plugge E. 2017. Systematic review and meta-analysis of the association between maternal smoking in pregnancy and childhood overweight and obesity. J Epidemiol Community Health, 71 (2), pp. 162-173. | Show Abstract | Read more

BACKGROUND: By 2020, it is predicted that 60 million children worldwide will be overweight. Maternal smoking in pregnancy has been suggested as a contributing factor. Our objective was to systematically review studies on this, thereby expanding the evidence base for this association. METHODS: Systematic review with meta-analysis, Prospero Registration number CRD42012002859. We searched PubMed, Embase, Global Health, Web of Science and the Grey literature. We included prevalence, cohort and cross-sectional studies involving full-term, singleton pregnancies. Published and unpublished studies through to 1 January 2015 in all languages, demonstrating an objective overweight outcome up until 18 years of age and data presented as an OR, were included. Quality assessment was undertaken using an adaption of the Newcastle-Ottawa scale. Statistical analysis was performed using Review Manager V.5.3. FINDINGS: The meta-analysis included 39 studies of 236 687 children from Europe, Australia, North America and South America and Asia. Maternal smoking in pregnancy ranged from 5.5% to 38.7%, with the prevalence of overweight from 6.3% to 32.1% and obesity from 2.6% to 17%. Pooled adjusted ORs demonstrated an elevated odds of maternal smoking in pregnancy for childhood overweight (OR 1.37, 95% CI 1.28 to 1.46, I2 45%) and childhood obesity (OR 1.55, 95% CI 1.40 to 1.73, I2 24%). INTERPRETATION: Our results demonstrate an association between maternal prenatal smoking and childhood overweight. This contributes to the growing evidence for the aetiology of childhood overweight, providing important information for policymakers and health professionals alike in planning cessation programmes or antismoking interventions for pregnant female smokers.

Fellmeth G, Fazel M, Plugge E. 2017. Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis. BJOG, 124 (5), pp. 742-752. | Show Abstract | Read more

BACKGROUND: Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration. OBJECTIVES: This systematic review and meta-analysis summarises the prevalence, associated factors and interventions for perinatal mental disorders in migrant women from low- and middle-income countries (LMIC). SEARCH STRATEGY: We systematically searched nine electronic databases and the grey literature using a predefined search strategy. SELECTION CRITERIA: Studies were included if they assessed pregnant or postpartum migrants from LMIC, used a structured tool and a case-control, cross-sectional, cohort or intervention study design. DATA COLLECTION AND ANALYSIS: Data was double-extracted. We calculated pooled prevalence of depression and weighted mean anxiety and depression scores. We calculated crude odds ratios from risk factor studies and summarised intervention studies descriptively. MAIN RESULTS: Forty studies were identified from 10 123 references. Pooled prevalence was 31% [95% condidence interval (CI) 23%-40%] for any depressive disorder and 17% (95% CI 12-23%) for major depressive disorder. Previous depression and lower social support were associated with perinatal depression. There were insufficient data to assess the burden of anxiety, post-traumatic stress disorder or psychosis in this population. CONCLUSIONS: One in three migrant women from LMIC experiences symptoms of perinatal depression. Social support is an important protective factor. Evidence on LMIC women relocating to other LMIC is lacking. Given the adverse consequences of perinatal mental illness on women and their children, further research in low-resource settings is a priority. TWEETABLE ABSTRACT: One in three migrant women from low- and middle-income countries has symptoms of perinatal depression.

Preston EC, Ariana P, Penny ME, Frost M, Plugge E. 2015. Prevalence of childhood overweight and obesity and associated factors in Peru. Rev Panam Salud Publica, 38 (6), pp. 472-478. | Show Abstract

OBJECTIVE: To determine the prevalence of and factors associated with childhood overweight and obesity among a cohort of children 7-8 years of age in Peru. METHODS: This was a cross-sectional secondary analysis of data from the Young Lives longitudinal study of childhood poverty. The sample was a cohort of 1 737 children 7-8 years of age in 2009. Prevalence of overweight and obesity was assessed using body mass index-forage Z-scores. Logistic regression was used to determine associations with a number of individual, household, and community factors. RESULTS: Prevalences of overweight and obesity were 19.2% and 8.6%, respectively. A prevalence of 32.0% and 23.5% overweight and obesity was found among males and females, respectively. High socioeconomic status, living in Lima, having a mother who was overweight or obese, being male, and being an only child or having only one sibling were associated with being overweight and obese at this age. CONCLUSIONS: This study shows a high prevalence of childhood and maternal overweight and obesity in Peru. In contrast to findings in many high-income countries, the findings in Peru indicate that children from wealthier households were more likely to be overweight or obese than those from poorer households. In addition, there is something particularly obesogenic about the Lima environment that merits further investigation, and several key issues to consider when targeting future interventions and research.

Awoh AB, Plugge E. 2016. Immunisation coverage in rural-urban migrant children in low and middle-income countries (LMICs): a systematic review and meta-analysis. J Epidemiol Community Health, 70 (3), pp. 305-311. | Show Abstract | Read more

BACKGROUND: The majority of children who die from vaccine-preventable diseases (VPDs) live in low-income and-middle-income countries (LMICs). With the rapid urbanisation and rural-urban migration ongoing in LMICs, available research suggests that migration status might be a determinant of immunisation coverage in LMICs, with rural-urban migrant (RUM) children being less likely to be immunised. OBJECTIVES: To examine and synthesise the data on immunisation coverage in RUM children in LMICs and to compare coverage in these children with non-migrant children. METHODS: A multiple database search of published and unpublished literature on immunisation coverage for the routine Expanded Programme on Immunisation (EPI) vaccines in RUM children aged 5 years and below was conducted. Following a staged exclusion process, studies that met the inclusion criteria were assessed for quality and data extracted for meta-analysis. RESULTS: Eleven studies from three countries (China, India and Nigeria) were included in the review. There was substantial statistical heterogeneity between the studies, thus no summary estimate was reported for the meta-analysis. Data synthesis from the studies showed that the proportion of fully immunised RUM children was lower than the WHO bench-mark of 90% at the national level. RUMs were also less likely to be fully immunised than the urban-non-migrants and general population. For the individual EPI vaccines, all but two studies showed lower immunisation coverage in RUMs compared with the general population using national coverage estimates. CONCLUSIONS: This review indicates that there is an association between rural-urban migration and immunisation coverage in LMICs with RUMs being less likely to be fully immunised than the urban non-migrants and the general population. Specific efforts to improve immunisation coverage in this subpopulation of urban residents will not only reduce morbidity and mortality from VPDs in migrants but will also reduce health inequity and the risk of infectious disease outbreaks in wider society.

Fellmeth G, Plugge E, Paw MK, Charunwatthana P, Nosten F, McGready R. 2015. Pregnant migrant and refugee women's perceptions of mental illness on the Thai-Myanmar border: a qualitative study. BMC Pregnancy Childbirth, 15 (1), pp. 93. | Show Abstract | Read more

BACKGROUND: Mental illness is a significant contributor to the global burden of disease, with prevalence highest in low- and middle-income countries. Rates are high in women of childbearing age, especially during pregnancy and the first year post-partum. Migrant and refugee populations are at risk of developing mental illness due to the multiple stressors associated with migration. The Thai-Myanmar border area is home to large populations of migrants and refugees as a result of long-standing conflict, poverty and unemployment in Myanmar. This study aims to explore perceptions of mental illness among pregnant migrants and refugees and antenatal clinic staff living and working along the Thai-Myanmar border. METHODS: Thirteen focus group discussions were conducted with pregnant migrants, pregnant refugees and antenatal clinic staff. Focus groups were held in one large refugee camp and two migrant health clinics along the Thai-Myanmar border. Thematic analysis was used to identify and code themes emerging from the data. RESULTS: A total of 92 pregnant women and 24 antenatal clinic staff participated. Discussions centered around five main themes: symptoms of mental illness; causes of mental illness; suicide; mental illness during pregnancy and the post-partum period; and managing mental illness. Symptoms of mental illness included emotional disturbances, somatic symptoms and socially inappropriate behavior. The main causes were described as current economic and family-related difficulties. Suicide was frequently attributed to shame. Mental illness was thought to be more common during and following pregnancy due to a lack of family support and worries about the future. Talking to family and friends, medication and hospitalization were suggested as means of helping those suffering from mental illness. CONCLUSIONS: Mental illness was recognized as a concept by the majority of participants and there was a general willingness to discuss various aspects of it. More formal and systematic training including the development of assessment tools in the local languages would enable better ascertainment and treatment of mental illness in this population.

Turner K, Foster C, Allender S, Plugge E. 2015. A systematic review of how researchers characterize the school environment in determining its effect on student obesity. BMC Obes, 2 (1), pp. 13. | Show Abstract | Read more

BACKGROUND: Obesity in early childhood is a robust predictor of obesity later in life. Schools provide unparalleled access to children and have subsequently become major intervention sites. However, empirical evidence supporting the effectiveness of school-based interventions against childhood obesity is of limited scope and unknown quality. The aim of this systematic review is to critically assess how researchers have characterized the school environment in determining its effect on childhood weight status in order to improve the quality and consistency of research in this area. We conducted a narrative review with a systematic search of the literature in line with PRISMA guidelines (2009). Original peer-reviewed research articles in English were searched from Medline, EMBASE, CENTRAL, CINAHL and PsycINFO databases from earliest record to January 2014. We included empirical research that reported at least one measure of the primary/elementary school environment and its relationship with at least one objective adiposity-related variable for students aged 4-12 years. Two authors independently extracted data on study design, school-level factors, student weight status, type of analysis and effect. RESULTS: Five studies met the inclusion criteria. Each study targeted different parts of the school environment and findings across the studies were not comparable. The instruments used to collect school-level data report no validity or reliability testing. CONCLUSIONS: Our review shows that researchers have used instruments of unknown quality to test if the school environment is a determinant of childhood obesity, which raises broader questions about the impact that schools can play in obesity prevention.

Barnett I, Ariana P, Petrou S, Penny ME, Duc LT, Galab S, Woldehanna T, Escobal JA, Plugge E, Boyden J. 2013. Cohort profile: the Young Lives study. Int J Epidemiol, 42 (3), pp. 701-708. | Show Abstract | Read more

Young Lives is an international longitudinal study investigating the changing nature of childhood poverty in four low-income countries [Ethiopia, India (Andhra Pradesh), Peru and Vietnam] over a 15-year period. In each country, the cohort is comprised of ≈ 2000 children aged between 6 and 18 months and up to 1000 children aged between 7 and 8 years, recruited in 2002 and sampled from 20 sentinel sites. The first survey data collection from primary caregivers and older children took place in 2002, the second in 2006-07 and the third in 2009-10. Data on the community contexts were collected to complement the household surveys. To elaborate and extend the quantitative data, longitudinal qualitative research with a subgroup of the children was carried out in 2007, 2008 and 2010-11. Topic areas covered included nutrition, health and well-being, cognitive and physical development, health behaviours and education, as well as the social, demographic and economic status of the household. Survey data from the study are archived in the International Section of the UK Public Data Archive.

Herbert K, Plugge E, Foster C, Doll H. 2012. Prevalence of risk factors for non-communicable diseases in prison populations worldwide: a systematic review. Lancet, 379 (9830), pp. 1975-1982. | Show Abstract | Read more

BACKGROUND: The burden of non-communicable diseases (NCDs) is disproportionately carried by low-income and middle-income countries and disadvantaged sectors of society such as prisoners. No systematic analysis has been done to assess the prevalence of poor diet, inadequate physical activity, and overweight and obesity in prisoners. We aim to synthesise current evidence and to highlight areas for action and further research. METHODS: We systematically searched online databases for reports published between 1948 and May, 2011. Studies were screened against eligibility criteria; two authors then independently extracted data with previously agreed proformas. The risk of bias was assessed for each study with a domain-based assessment. Data on body-mass index and physical activity were presented in forest plots; no overall estimates were calculated on account of data heterogeneity. Available data from the population subgroup most similar in terms of age and sex were used to calculate age-adjusted and sex-adjusted prevalence ratios, which estimate the likelihood of insufficient activity and obesity prevalence in prisoners compared with the national population. FINDINGS: 31 eligible studies were reported in 29 publications, including more than 60,000 prisoners in 884 institutions in 15 countries. Male prisoners were less likely to be obese than males in the general population (prevalence ratios ranged from 0·33 to 0·87) in all but one study (1·02, 0·92-1·07), whereas female prisoners were more likely to be obese than non-imprisoned women in the USA (1·18, 1·08-1·30) and Australia (prevalence ratios ranged from 1·15 to 1·20). Australian prisoners were more likely to achieve sufficient activity levels than the general population compared with prisoners in the UK (prevalence ratio 1·19, 95% CI 1·04-1·37, for women in Australia in 2009 vs 0·32, 0·21-0·47, for women in the UK; prevalence ratios ranged from 1·37 to 1·59 for men in Australia vs 0·71, 0·34-0·78, for men in the UK). Female mean energy intake exceeded recommended levels and sodium intake was about two to three times the recommended intake for all prisoners. INTERPRETATION: Contact with the criminal justice system is a public-health opportunity to promote health in this vulnerable population; the costs to the individual and to society of failing to do so are likely to be substantial. Improved monitoring and further research is essential to inform appropriate targeting of public health interventions. FUNDING: Oxford University Department of Public Health, Oxford University Hospitals NHS Trust.

3053