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Section 2 The Evidence Basis of the
Demonstration Projects
Each of the
DPs was developed within the context of
an evidence base relating both to general issues, notably
the effect of deprivation on health, and to the
effectiveness of community-based interventions proposed. In
this section we consider how strong the evidence -
including new evidence emerging during the projects'
lifespan - was in relation to each
DP and how closely the
DPs matched the evidence-base. Any
assessment of the effectiveness of
DPs should take account of these issues
since a failure to demonstrate might reflect the weakness
of the initial evidence, rather than a failure of
implementation.
2.1 Starting Well (
SW)
2.1.1 The demonstration project
SW aims to demonstrate that child and
family health can be improved via an intervention
comprising two integrated components: a programme of
intensive home-visiting combining parental support and
parenting education, and a strengthened network of
community-based support services for children and parents.
The parenting education programme was not specified in the
original bid, but following a review of several
possibilities, the 'Positive Parenting Programme' (Triple
P), developed by Sanders et al. (2000) in Australia, was
chosen by
SW and has been delivered both on an
individual and group basis. The dual approach, combining
family and community perspectives, reflected a belief that
by adopting a broader ecological model of health, the
impact of the home visiting programme is likely to be
enhanced.
The project is located in two disadvantaged communities
in Glasgow. To date, 1555 families with a child born from
December 2001 to December 2003 have participated (98% of
the total number of births). 19% of participants were
recruited (and home visited) in the ante-natal period, the
remainder (81%) having their first home visit soon after
the birth of the child. The intervention consisted of
regular visits from health visitors supplemented by lay
'health support workers' up to the child's third birthday.
One of the areas (Glasgow South) contains a relatively high
proportion (18%) of families of South Asian origin,
reflecting one of the demonstration project's aims; that
is, to address the needs of black and ethnic minority
groups.
2.1.2 The evidence base
The original proposal for
SW was accompanied by a literature
review of the evidence relating to the role of poverty for
child and maternal health and implications for parenting
together with an assessment of the evidence on the
effectiveness of family interventions in ameliorating these
effects. Almost all the available evidence on interventions
was derived from randomised controlled trials (
RCTs), involving allocation of families
into an intervention (nurse visiting) and control arm (no
nurse visiting). Two systematic reviews of those studies
were also referred to. While the weight of evidence was,
and remains, supportive of the
SW rationale, a number of points, some
of which were mentioned in the original
SW literature review, are worth noting
here.
- Both systematic reviews (MacMillan et al., 1993;
Hodnett & Roberts, 1999) commented on a range of
methodological problems associated with the evaluation
studies, including small sample sizes, inadequate
randomisation, lack of blinding in evaluation (Johnson
et al., 1993) and problems of attribution (intervention
or extraneous factors). Even in the Elmira trial (Olds
et al., 1986), methodologically judged the best
(MacMillan et al., 1993), the investigators
acknowledged that an intervention effect could be
attributable to pre-existing differences between groups
and/or reporting bias.
- Both systematic reviews offered only cautious
support, each noting variability in results between
studies and between outcomes in the same study. Some
studies, including one in England (Lealman et al.,
1983), demonstrated no intervention effect, or effects
not in the expected direction. Many of the reported
differences did not reach conventional levels of
statistical significance, and some were misinterpreted.
For example, the
SW literature review reported the
results of a meta-analysis as showing 'a significant
preventive effect of home visiting on the occurrence of
childhood injury' (p.9) while the original review drew
attention to the fact that the pooled odds ratio of 6/8
trials reporting lower injury encompassed 1.0 (Hodnett
& Roberts, 1999). The error in the
SW review was corrected in the later
evaluation proposal, the finding being described as a
'non-significant trend' (Gray et al., 2000, p.4).
- Almost all studies referred to were restricted to
first born children, and most focussed on more deprived
populations. Support for intervention effects is often
found in specific sub-groups of study participants,
typically the most vulnerable. Thus, in the Elmira
trial, at age two, significant differences between
nurse visited and control groups were found only among
young (<19) unmarried mothers of low socioeconomic
status (
SES) (Olds et al, 1986). In a
long-term follow-up (age 15), an intervention effect on
delinquency and substance use was similarly restricted
to this group (Olds et al., 1997). In another trial of
a 'therapeutic programme' to promote maternal
competence and parenting, the effect of the
intervention was observed only among low
IQ mothers, higher
IQ mothers doing better with a
traditional programme (Barnard et al., 1988). These
results generally underpin recommendations to target
interventions either at vulnerable families in the
community (Gutelius, 1977) or (less usually) to
'communities with high concentrations of low-income
married women' (Olds et al., 1997, p.642). All
available evidence, however, refers to
RCTs of families rather than
communities.
- The best evidence for intervention effects are also
associated with particular characteristics of the
intervention: namely early (ante-natal) contact,
frequent home visiting by nurses in both the ante-natal
and post-natal period and long term (up to 5 years)
contact (MacMillan et al., 1993). There was also some
evidence that programmes with a 'therapeutic' ethos are
more effective (Barnard et al., 1988; Gutelius, 1977).
In addition, the
SW review made much of the view
expressed by Olds and others that effectiveness is more
likely when proximal (e.g. home support) and distal
(e.g. health and community services) influences work
synergistically, a view closely related to an
ecological model of health promotion.
- Evidence in relation to Triple P (not provided in
the initial
SW document) supports the
developers' contention that it 'has the strongest
empirical support of any intervention with children'
(Sanders, 1999, p.72). However, its evaluation has
almost entirely been based on
RCTs involving children and families
with identified problems, such as maternal depression
or conduct problems in the child, either receiving or
in need of treatment. The extent to which the effects
are generalisable to all children, and identifiable at
the community level, is much less certain.
- While there is some evidence that effects diminish
with time (Gutelius, 1977; Kendrick et al., 2000),
other studies demonstrate mixed results, and some point
to effects that persist or emerge later. In the Elmira
trial, although no significant differences in
HOME scores were found between
intervention and control groups at 34 and 46 months
(Olds et al., (1986; 1994), mothers in the intervention
groups had fewer subsequent pregnancies and at age 15
their children had lower rates of substance use,
arrests and convictions (Olds et al., 1997). These
findings raise the possibility of 'sleeper' effects
(only emerging over time) though none of the
RCTs, nor the systematic reviews,
mention this.
- Almost all studies were and remain
US-based, raising the question of
transferability to other national/cultural contexts.
This issue was mentioned in the
SW review, which noted that an exact
replication in the
UK was unlikely because existing
health visiting services routinely do some of the work
of (intervention) nurses. The implication of this
(which was not commented on) is that any intervention
effect of enhanced health visiting is likely to be less
in the
UK than in the
US.
- While several of the intervention studies included
minority ethnic groups, none specifically addressed the
question of the extent to which programmes were either
applicable or effective in those groups. In the
SW review, which gave prominence to
the needs of Asian families, no studies of this ethnic
minority were referred to.
In summary, the evidence on the effectiveness of home
intervention programmes which was available to the
SW team at the start of the project was
less conclusive than often supposed. Many of the studies
had methodological flaws, effect sizes were generally small
and often confined to the most vulnerable of sub-groups.
The best evidence for an intervention effect came from the
most intensive, therapeutically oriented programmes of long
duration.
Since then, further systematic reviews (Kendrick et al.,
2000; Elkan et al., 2000) have highlighted methodological
problems and urged caution in extrapolating beyond the
US. Nevertheless, the results have been
moderately encouraging. For example, in Kendrick et al's
(2000) meta-analysis of 12/17 trials, a significant effect
of home visiting on the quality of the home environment (as
measured by the
HOME score) was found, and some
significant effects on other dimensions of parenting were
also demonstrated in 20/27 studies. The authors noted,
however, that their conclusion rested on an assessment of
statistical significance rather than (as preferred) effect
size. They also noted that since only 4 of 27 studies were
from the
UK 'caution must be exercised in
extrapolating the results to current
UK health visiting practice' (p. 443).
Very recently, the Health Development Agency (
HDA) (2004), have conducted a review of
reviews of home-visiting programmes (including Kendrick et
al). Their conclusion is equally cautious, the evidence
being inconclusive in relation to several child outcomes
(e.g. child abuse), though more positive for others (e.g.
childhood injury). There is also some good evidence of
positive effects on various dimensions of parenting or
mother-child interaction.
2.1.3 Differences in design
There are a number of ways in which
SW differed from interventions of proven
effectiveness: these differences might be expected to
affect its capacity to demonstrate an effect in Scotland.
The most important of these are:
- The setting - Recognised throughout,
the most obvious difference resides in the different
health care systems in the
US and
UK, the latter having a system of
statutory health visiting which routinely provides some
of the features of intensive home visiting.
Intervention effects in Glasgow are, therefore, likely
to be smaller than those observed in the
US trials. There are in addition
cultural differences relating to the acceptability of
such interventions which might impact on uptake,
motivation and compliance, and hence effect.
- The target population - The
SW target population differs from
the trials. Rather than randomising families to
intervention and control arms, it targets whole
communities, so that intervention effects must be
detected through comparison with a control community.
This reflects the underlying philosophy of the project,
particularly the adoption of an ecological model, but
there is no direct evidence of such a community-wide
effect. Given that several (
US) studies have demonstrated
effects only on particularly vulnerable groups, it
could be that the comparison of communities will
obscure important effects in particular sub-groups. In
principle this issue can be addressed by sub-group
analysis, but only if the analyses are specified in
advance and, where necessary, built into the
design.
- Ethnic minorities - One of the
SW areas (Glasgow South) includes a
relatively high proportion of families of South-Asian
origin, reflecting the prominence accorded to ethnic
minorities in the proposal. While this may be desirable
for a variety of reasons, there is no evidence
supporting the effectiveness of home-visiting in this
group, nor is it known how appropriate Triple P is in
this context. Given the cultural differences in family
structure and parenting, it is also unclear how
applicable the key
HOME measure is for this group. It
is possible, therefore, that ethnic minority families
will be a separate case, complicating between community
comparisons.
- The target child -
SW targets all children born to
mothers in the two intervention areas while almost all
the trials focus on first born children. This
difference is not commented on in any document and it
is neither clear whether this is likely to have any
effect, nor what direction this is likely to be in. It
is, however, possible that an effect would be more
pronounced in first-born than subsequent children.
- The intervention -
SW involves a dual intervention
strategy combining home visiting with strengthened
community support. In respect of both, the
SW design is a departure from that
of the interventions providing the evidence base.
- Home Visiting - while
SW contains many features of the
effective interventions (frequent visiting with a
specified educational and therapeutic content) it is
clear that only a small proportion (19%) of families
were visited in the ante-natal period. The best
available evidence suggests that contact before the
baby's birth is important. Reduced contact in this
period might weaken an intervention effect.
- Triple P - although regarded as the most
evidence-based of all home intervention programmes,
most of the evidence about effectiveness refers to
specific sub-groups, notably children with conduct
problems. As widely acknowledged, it is also not
validated in a Scottish population, nor with respect to
ethnic minorities such as those of South Asian
origins.
- Community support - although recognised as likely
to enhance the effectiveness of home visiting, there is
no direct evidence from
RCTs on this issue.
The
SW demonstration programme, therefore,
had several characteristics which distinguished it from
previous effective interventions which meant that there
were departures from the evidence-base template. Although
there were good reasons for this, it highlights the
innovative nature of
SW and further underscores the
importance of its evaluation. As outlined in the
introduction, the
DPs were required to both utilise the
evidence-base and to be creative. The key, therefore, is
explicit clarity over what is evidence-based, what is new
and what is an application to a new context.
2.2 Healthy Respect (
HR)
2.2.1 The demonstration project
HR is a multi-strand programme (made up
of 12 projects) to promote positive sexual health and
relationships among young people. It has two overarching
aims (1) to reduce teenage pregnancies and prevent the
spread of Sexually Transmitted Infections (
STIs) (2) to communicate learning about
'how and why outcomes emerge' (original bid, p.2) to
promote transferability. As originally specified, within
these 2 aims, a number of specific objectives were
outlined, including (Aim 1) promoting openness in
discussion about sexual health, nurturance of self-esteem
and responsibility and discouragement of coercive sex, and
(Aim 2) the development of an
HR website.
HR, though predominantly incorporating
existing organisations in Lothian, also developed
innovative projects. Project B, Looked After and
Accommodated Young People (
LAAYP) was the only project that existed
before the establishment of
HR. Following the original bid (November
2000), which did not identify specific projects, a revised
submission (project plan, July 2001) identified 12 projects
(Projects A-L) and 19 reporting components. These projects
referred to a range of existing and projected initiatives
located in diverse settings, including improvements in the
uptake of contraception post termination (A) and Chlamydia
screening among women presenting for emergency
contraception (D) in family planning clinics, provision of
postal testing kits for Chlamydia (C) via several outlets,
sexual health promotion in Further Education colleges (E)
and schools (G), contact and support for specific groups
such as
LAAYP, (B) and Lesbian, Gay, Bisexual
and Transgender Youth (F) and parents (I) and a project
focussing on media campaigns (L). In combination, these
projects comprise
HR.
2.2.2 The evidence base
In the
HR proposal, there was no separate
review of the evidence on interventions to improve sexual
health amongst young people. The only forms of 'evidence'
presented were descriptive, with references to official
reports highlighting the importance of sexual health
education, self-esteem, multi-agency working and the role
of poverty and a series of tables/figures detailing the
sexual health profile of young people in Scotland, and
where possible Lothian. For example, data from the Health
Behaviours of Scottish School Children (
HBSC) Scotland survey (Todd et al.,
1999) was used to demonstrate the increasing proportion of
15 year-olds with sexual experience from 1990 to 1998, and
the proportion in 1998 not using contraception at last
intercourse. The implicit assumption throughout the
HR proposal was that these Lothian data
'speak for themselves' and were simply further testimony to
the accepted wisdom that the sexual health of young people
needs to be improved. The following points are
noteworthy:
- Except in the most general terms, the
HR bid was characterised by the
absence of an explicit evidence-base. The evidence
adduced in support of
HR was general, patchy and possibly
selective. Much is made of the quality of
relationships, and particularly the importance of
self-esteem, but no supporting references were
provided. While criticism of the self-esteem thesis in
relation to risk behaviours is recent, some evidence on
this issue was available at the time of the proposal
(West and Sweeting, 1997).
- Most importantly, despite the fact that
HR is an intervention (albeit
multi-faceted), no reference was made to any
intervention study in sexual health which might provide
a rationale for the effectiveness either of the whole
programme or any of its components. For example, there
was no mention of the extensive literature on sex
education in schools, (e.g. Wellings et al., 1995), nor
was there any reference to a number of systematic
reviews on (mainly
US) sexual health education
programmes. Although these systematic reviews identify
several studies showing no intervention effects, on
balance they provide evidence for the effectiveness of
certain programmes in reducing certain outcomes such as
underage sex and/or increased condom use (Kirby et al.,
1004; Kirby, 1999;
NHS Centre for Reviews, 1997). It
can only be assumed that this literature was either
known to
HR but not made explicit, or that it
was entirely taken for granted that sexual health
education was a good thing regardless of its
effectiveness.
- HR has as one of its goals the
promotion of openness in sexual health matters. In
support of this, reference was made to the low teenage
pregnancy rate in the Netherlands, together with the
view that this results from a positive and open sexual
health culture. Although this is an admirable goal,
there was no explicit acknowledgement of any problem of
transferability to the Scottish context.
For all the
DPs, the evidence base is constantly
developing, and needs to be updated as new studies and
reviews are published. In the case of
HR, the evidence base was unacknowledged
and possibly unknown to the bidders, although at a later
stage in the bidding process (some time between January and
April 2001), at the request of the Scottish Executive, an
outline of the evidence base was prepared which outlined
the Healthy Respect component project, its rationale and
the evidence base for the intervention. Since its inception
important new evidence has emerged which challenges parts
of its underlying rationale. The most important new study
is the
MRCSHARE trial which provided the model for
the sexual health intervention in the
HR schools project (G) and the model for
its evaluation. Disappointingly, the results of the trial
(published in 2002, but made available to
HR in July 2000), did not show an effect
of the intervention on reported age of first intercourse or
condom use, two of
HR's key targets (Wight et al., 2002).
However, consistent with other trials (Mellianby et al.,
1995), improvements in knowledge were demonstrated, and it
remains possible that differences in behavioural outcomes
will be found in later follow-ups and by reference to
termination rates. While differences between the
HR project and the
MRC intervention (
HR has established links with health
services and developed multi-disciplinary working) might be
expected to increase an intervention effect, the evidence
from the
MRC study clearly runs counter to the
expectations of
HR and challenges the rationale. This
raises the question of how a
DP, or its sponsor, should react when
contrary evidence emerges after the project is underway. In
this case, the new evidence appears to have made no
difference since the results of the
SHARE trial were known to
HR when the project bids were being
developed.
2.2.3 Differences in design
Unlike
SW, without an explicit evidence base
for
HR, there is no effective intervention
template against which to assess the design of
HR.
HR proceeded as if it were an entirely
new project, again highlighting the need for
evaluation.
2.3 Have a Heart Paisley (
HAHP)
2.3.1 The demonstration project
HaHP is an area-based, multi-component,
multi-agency project with a strong community focus that
aims to prevent coronary heart disease (
CHD), to promote good health and to
reduce health inequalities in Paisley, a town with high
levels of
CHD and of deprivation.
The original proposal set out a framework for a wide
range of health promoting activities targeting the main
risk factors for
CHD and encompassing both primary and
secondary prevention. The
NHS, local authorities, voluntary groups
and community groups are all partners in the development
and implementation of the project. The
HAHP framework encompassed both primary
and secondary prevention of
CHD. Four geographical locality networks
provided the framework within which risk factor modifying
activities are supported, co-ordinated and targeted. A
fifth network co-ordinated the secondary prevention work
aimed at people in high risk groups such as those with
established
CHD. Marketing activities aimed to raise
awareness of the
HaHP activities and brand and to endorse
positive lifestyle messages.
A few defined initiatives were included in the initial
proposal, such as the development of
CHD registers as a basis for improved
secondary prevention. However most of the component parts
of the project were not defined in detail. The partner
agencies were invited to submit specific sub-projects for
funding from
HaHP - focussing on the three main risk
factors: smoking, diet and physical activity. Training
needs were also seen as a priority issue.
2.3.2 The evidence base
Since the 1970s, many community based or population
based intervention studies have been carried out for the
prevention of
CHD (Puska et al., 1995; Ebrahim and
Davey Smith, 2001; Farquhar et al., 1990; Luepker et al.,
1994). Although the original proposal for
HaHP included an appendix on the
evidence base, this was mainly devoted to describing the
North Karelia study, with some other examples of prevention
initiatives. The proposal did not include a comprehensive
and critical appraisal of the admittedly large and complex
literature on community based
CHD prevention studies or on risk factor
based interventions. This would have been impossible within
the time available to the bidders. However, a good summary
was included as part of the successful bid to evaluate
HaHP (Hanlon et al., 2000) and later on
a detailed review was conducted as part of the evaluation
(Blamey, A., 2002).
This was set up in Finland in the 1970s (Puska et al.,
1985; Vartiainen et al., 1994) and is the best known of the
many community based
CHD prevention initiatives. It has been
extensively evaluated, through a series of population
surveys and other methods (Puska, 1995). The project built
on the support of local community leaders and the general
public and was intended to provide a unified and
comprehensive approach to
CHD prevention. It involved the media,
workplaces, primary care, hospitals, schools and local
communities. A very wide range of initiatives were
implemented, including training programmes, mobilisation of
public support through local leaders, formation of
housewives groups and targeting of grocery shops and the
food industry.
Over the duration of the study, there has been a
substantial fall in
CHD mortality rates for
CHD in North Karelia and in levels of
risk factors. However, a similar downward trend is seen
throughout all parts of Finland, raising the hotly debated
question of how far the mortality decline is attributable
to the specific interventions in the programme (Ebrahim and
Davey Smith, 2001).
- Other community based
interventions
In the 1980s several other influential community based
studies were conducted in the
USA, such as the Stanford Heart Disease
Prevention Programme, Stanford Five Cities Report,
Minnesota Heart Health Programme and Pawtucket Heart Health
Programme (Farquhar et al., 1990; Luepker et al., 1994;
Carleton et al., 1995). In each case, the differences
between the intervention and comparison areas in risk
factor modification were small or non-significant and the
attributable effect on mortality was also disappointing.
For example, a report from the Stanford Five Cities project
found a similar decline in disease rates in intervention
and control cities, suggesting that influences outwith the
programme accounted for the observed changes.
Within the
UK, a community based demonstration
programme in Wales, aimed at reducing risk factors for
CHD, was set up in the 1980s. Heartbeat
Wales drew on the experiences of the studies in Finland and
the United States. While a reduction in reported smoking
prevalence and improvements in dietary choice were
observed, there was no net intervention effect for the
programme areas over and above the observed change in the
control area of
NE England (Tudor-Smith et al., 1998).
The investigators concluded that 'with hindsight, the
difficulties of evaluating such a complex multifaceted
intervention were underestimated. Further debate on the
most appropriate methods for assessing the effectiveness of
community based health promotion programmes is called
for.'
- Multiple risk factor intervention
studies
In parallel with these community based studies, there
have been several large
RCTs of multiple risk factor
interventions in reducing
CHD mortality. Ebrahim and Davey Smith
reported a systematic review and meta-analysis of
RCTs in workforces and in primary care
in which individuals were randomly allocated to more than
one of six interventions (stopping smoking, exercise,
dietary advice, weight control, antihypertensive drugs and
cholesterol lowering drugs). The changes in risk factors
were modest and related to the amount of drug treatment
used. Interventions using education, with or without drugs,
were more effective in people with hypertension and in
other high-risk groups. (Ebrahim S., Davey Smith G.,
1997).
In contrast to the equivocal evidence on community based
programmes for primary intervention, there is a wealth of
good evidence from
RCTs and observational studies about the
effectiveness of secondary prevention of
CHD - in people who already have signs
or symptoms of the disease. In addition to demonstrated
evidence about the effectiveness of individual
interventions there is also evidence from a systematic
review that multidisciplinary disease management programmes
improve the processes of care, reduce admissions and
enhance quality of life in patients with
CHD, although the impact on survival and
recurrent heart attacks remains uncertain (McAlister et
al., 2001). Much of this evidence was available to the
HaHP team at the start of the programme
and developing a systematic approach to implementing
evidence-based guidelines was a major component of the
secondary prevention project.
In summary, although some components of
HaHP, notably the secondary prevention
initiatives have an evidence base, evidence for the
effectiveness of community based prevention programmes is,
at best, equivocal. It certainly does not consistently
demonstrate additional benefit in accelerating the
background secular trends in health behaviour and in
CHD mortality reduction which are
apparent in Western countries.
2.3.3 Differences in design
Given the lack of a good evidence base for
HaHP as a whole, the design of the
demonstration project only compounds the difficulties. The
problems in designing and implementing an effective
evaluation of population based projects like this have
previously been highlighted (Tudor-Smith et al., 1998;
Puska, 2000).
The
HaHP project has also taken place
against a background of falling
CHD mortality rates in Scotland and
there is little realistic chance of demonstrating
additional benefits in accelerating these trends. The
secondary prevention elements had more potential to
demonstrate effectiveness and to highlight useful lessons
for other parts of Scotland. In addition to this lack of a
strong evidence base for community-wide
CHD interventions as a whole, there are
a number of other ways in which the design of an effective
evaluation of the
HaHP project was problematic. The most
important of these are:
Both the intensity and the quality of the interventions
used in most community based intervention studies are
difficult to measure and this was particularly true of
HaHP.
Many small projects were funded with variable levels of
activity, both over time and throughout the geographical
area. This made it difficult to identify which parts of the
project might have an effect. Many of these specific
interventions were not evidence based.
There was anecdotal evidence that, prior to
HaHP, levels of some health promoting
interventions such as smoking cessation support, were lower
in Paisley than elsewhere in Scotland. This could tend to
exaggerate any benefit for
HaHP.
In addition,
HaHP took place against a background of
many national initiatives on improving health in Scotland.
These would have an impact on the population of Paisley and
would make it very difficult to isolate any specific
benefits from
HaHP.
Although mortality from
CHD in Scotland remains amongst the
highest in developed countries, death rates have fallen
substantially over the past 25 years and this trend is
continuing throughout the whole country. The population of
Paisley has high levels of deprivation and this is
associated with high levels of
CHD. There are significant cultural
differences between the intervention area and North Karelia
which are likely to impact on uptake, motivation compliance
and hence effectiveness.
2.3.4 Summary
A major problem for
HaHP is that community based
CHD prevention studies have failed to
show a clearly attributable effect, possibly even in the
case of North Karelia.
HaHP took place against a background of
falling
CHD mortality rates in Scotland. It had
little realistic chance of demonstrating additional
benefits in accelerating these trends.
The secondary prevention elements had more potential to
demonstrate effectiveness and to highlight useful lessons
for other parts of Scotland.
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