Areas Of England Research Articles

Area inequalities in fruit and vegetable intake in England: a spatial microsimulation, cross-sectional study

BackgroundIndividual-level data of health outcomes and their contributing factors are rarely available at a neighbourhood level, hindering local efforts to address complex issues such as dietary behaviours and their associated inequalities. Spatial microsimulation can be used to approximate individual-level data for small areas (eg, lower or middle super output areas), creating novel synthetic data to support local decision making. We aimed to estimate small-area fruit and vegetable intake to explore geographical inequalities of diet in England. MethodsIn this spatial microsimulation, cross-sectional study, we performed the spatial microsimulation using individual-level data from the 2014–19 UK National Dietary and Nutritional Survey (NDNS) and aggregated data from the 2011 UK Census. Iterative proportional fitting was done in R (version 1.4.1106) to estimate daily servings of fruits and vegetables for each lower super output area (n=32 844) in England. Internal validation techniques such as measures of total absolute error were evaluated and external validation including comparison to variables of interest (eg, correlation with obesity) undertaken. Findings3633 adults aged 16 years or older (2092 women and 1541 men) were included in the analysis. We estimated that 26% of adults in England meet the daily recommendations of fruit and vegetable intake, with 7% consuming fewer than one serving per day. This result mirrored NDNS findings as expected. Fruit and vegetable consumption was unevenly distributed within and across regions in England (16–46% meeting the five-a-day recommendations). There were higher rates of fruit and vegetable consumption than those among populations in the least deprived neighbourhoods with 32% meeting daily recommendations versus 20% in the most deprived. Preliminary model validation suggests estimates were robust for internal validation. External validations were mixed. InterpretationWide geographical inequalities in fruit and vegetable consumption exist across England, varying greatly by level of deprivation. This study presents a novel framework for small area estimation of diet indicators and could support better nuanced local decision-making. FundingEconomic and Social Research Council, North West Social Science Doctoral Training Partnership (reference 2107539).

COVID-19 recovery from the community perspective in Middlesbrough: a coproduction cross-sectional study

BackgroundPeople younger than 65 years living in deprivation are nearly four times more likely to die of COVID-19 and, in Middlesbrough, life expectancy is 12·6 years lower than those in the least deprived areas of England. We aimed to examine COVID-19 recovery from the perspective of members of the local communities in Middlesbrough. MethodsIn this coproduction cross-sectional study, we used purposive, semi-structured interviews, with recruitment via social media and community groups. Interviews were conducted via telephone or Microsoft Teams. Participants needed to be a resident of Middlesbrough and aged 18 years or older. Particular engagement was sought amongst those aged 18–30 years (n=15), older than 50 years (n=20), and individuals identifying as Black, Asian, or minority ethnic (n=22), or those residing in a TS1 or TS3 postcode area (n=23), with both areas being associated with high rates of deprivation, and Middlesbrough ranking fifth highest according to the 2019 English Indices of Deprivation (ONS, 2019). Interviews were transcribed verbatim and subjected to thematic analysis, coded blind to eliminate bias. Ethical clearance was granted by the Teesside University Ethics Sub-Committee at which time recruitment commenced. Written and verbal consent was obtained by the research team before any interviews started. FindingsBetween Oct 1, 2020, and March 1, 2021, we recruited and interviewed 52 people (26 women, 25 men, and one non-binary person), generating over 50 h of interview transcripts. From analysis of these transcripts, eight primary themes emerged: authority, autonomy, community, economy, fairness, framing, future, and wellbeing. Participants spoke of feeling abandoned by authorities, mistrusting of official information, and worries around the ability of their communities to survive financially through lockdowns. InterpretationDevelopment of social capital is crucial to the development of a COVID-19 recovery strategy. Providing people with choices tailored to their local setting is fundamentally important. Mental health is a priority as we emerge from lockdown, particularly young people. Communication from authorities must be carefully framed, avoiding imperatives where possible. Better understanding is needed for the reasons behind mistrust of official information. FundingMiddlesbrough Council.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration Current Controlled Trials ISRCTN15568163. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

Implementing a set of health promoting processes in English secondary schools: A comparative case study

ObjectiveTo understand the enablers and barriers to implementing a set of adaptive processes aimed at supporting secondary schools to reflect on and subsequently address how they could adjust school practices, culture and the environment to create a whole school approach to promoting healthy lifestyles. Study designA qualitative, comparative case study. MethodsTwo in depth case studies were created of two purposefully selected schools in low socio-economic areas of South West England. Data were collected via meetings, observations, field notes, interviews and audit. Interviews were transcribed verbatim. Individual thematic analyses were conducted for each school and a comparative analysis approach was used to understand the barriers and enablers across both cases. ResultsSchools were supported to use a health-promoting lens and identify feasible improvements through an adaptive and context specific process. The school environment and ethos were identified as the areas where schools could conceive the most adjustments to enhance the promotion of healthy lifestyle choices. With the lack of government policy for health promotion in schools (HPS), the Head teacher's approach to health was key to making meaningful changes. ConclusionsHealth promoting school approaches need to be adaptive to local context, actively involve community partners and link to local initiatives where possible, with support from Head teachers and business managers. Starting with what teachers, pupils and parents see as the barriers to health can create a whole school ethos for broad reaching and sustainable HPS programmes.

Coastal adaptation to climate change through zonation: A review of coastal change management areas (CCMAs) in England

Climate change and accelerated rates in sea-level rise are expected to increase flooding and erosion on the world's coastlines. Coastal managers and planners face the challenge of helping communities to adapt to the changing coast. Traditionally hard engineering has been used to defend communities on the coast, but as this option becomes unsustainable and financially unviable, coastal managers are increasingly employing planning policy to mitigate the risk posed by coastal change. Zonation of coastal change areas and delineation of erosion extents, such as set-back lines, are used globally to restrict development in the coastal zone. In England there is policy in place to allow planning authorities to restrict certain development in areas expected to be affected by coastal change. This study aims to examine how coastal planning authorities in England have implemented coastal change adaptation policies, specifically Coastal Change Management Areas (CCMA). These areas should include sections of coast that will experience significant change over the next 100 years through erosion, accretion or flooding. Through an analysis of planning documents, we have found that since the policy was introduced in 2012, only 15% of coastal planning authorities have designated a CCMA, with just 5.7% of the coast of England designated as a CCMA. We have found that inadequate and ambiguous guidance has reduced the effectiveness of the national policy with coastal planning authorities unsure of which datasets to apply for delineating areas of coastal change. This has led to vulnerable coastal areas being omitted from CCMAs. The datasets that are available for mapping the coastal change areas are found to vary in erosion extent and do not account for expected increases in the rate of sea-level rise. We suggest that for coastal zonation and climate change adaptation policy to be successful, a robust methodology, including a classification of coastal typologies and their response to sea level rise, is needed to delineate the extent of erosion or coastal change over the next 100 years. Understanding and mapping coastal response to sea level rise will aid planning authorities to build more resilient communities on the coast.

Optimising the Spatial and Production Input Features to Improve Efficiency of Hill Farm Production Systems

Integration of crop and livestock production systems (ICLS) represents a method for enhancing the sustainability of agricultural systems. Introducing more diversified farm production plans increases profitability and resilience by minimising the negative environmental impacts of agricultural production. Examining farm businesses located in Less Favoured Areas (LFAs) of England, we investigate how conversion into more integrated systems impacts on profitability. Thus, providing knowledge that can enable structural changes on the farm level towards enhancing financial performance and the sustainable intensification of the production system. Through Linear Programming (LP), four distinct optimisation scenarios are estimated, demonstrating the different dynamics between more specialised and more integrated-diversified (intensified) production systems. Data regarding physical and financial performances of 139 farm businesses were derived from the Farm Business Survey (FBS) for the accounting year of 2013–2014. Our findings suggest that there is a lot of potential for increasing profitability of hill farms through optimisation of ICLS. Policy interventions may accommodate productivity challenges within the LFAs via the construction of networks of transferrable knowledge to enable farmers gain knowledge on benefits emerging from ICLS. Hence, promote strategies and risk mitigation practises that could allow hill farmers to develop a sustainably intensified production system that is maximising the production capacity of the available natural resources.

High-resolution spatiotemporal analysis in 6,791 English areas reveals declines in life expectancy

BackgroundHealth inequalities in the UK and other advanced economies are receiving renewed attention by the public and governments in light of the Covid-19 pandemic. Current data on mortality and longevity in England lack precision either in space or in time. We estimated trends from 2002 to 2019 in life expectancy for all 6,791 English Middle-layer Super Output Areas (MSOAs, median population 7,985 in 2019).MethodsWe used data for all deaths in England from 2002 to 2019 with information on age, sex and MSOA of residence and data on population by age, sex and MSOA. We used a Bayesian hierarchical model to obtain stable estimates of age-specific death rates by sharing information across age groups, MSOAs and years. We used life-table methods to calculate life expectancy at birth by sex and MSOA.ResultsIn 2002-2006 and 2006-2010, the vast majority of MSOAs experienced a life expectancy increase for both sexes. In 2010-2014, female life expectancy decreased in 322 (5%) of MSOAs for women. By 2014-2019, the number of MSOAs with declining life expectancy was 1,178 (17%) for women and 635 (9%) for men. The life expectancy increase from 2002 to 2019 was smaller where life expectancy had been lower in 2002, mostly northern urban MSOAs, and larger where life expectancy had been higher in 2002, mostly MSOAs in and around London. As a result of these trends, the gap between the lowest and highest MSOA life expectancy increased from 2002 to 2019, to reach 20.6 (95% credible interval 17.3-24.4) years for women and 27.2 (23.4-31.7) years for men.ConclusionsThis study highlights not only rising inequality, but also declining life expectancy in a large proportion of English communities. The post-Covid rebuild policies in England must include pro-equity economic and educational policies, and expansion of public health and healthcare.Key messages Between 2014 and 2019, 17% and 9% of communities in England underwent a decrease in life expectancy for women and men respectively, highlighting the immediate need for equity-focussed policies.For women, 2% of small areas in England have experienced a long-term decline in life expectancy between 2002 and 2019.

Excess mortality in England during the COVID-19 pandemic

IntroductionExcess mortality monitoring is not dependent on completeness or consistency of coding of causes of death and captures deaths caused directly and indirectly by COVID-19. It takes account of existing inequalities in the baseline rates and shows the additional impact of COVID-19. We report weekly on excess mortality by age, gender, geographical area, deprivation, and ethnicity.MethodsA quasi-Poisson model was fitted to deaths data for 2015-2019 to estimate expected mortality in population sub-groups each week during the COVID-19 pandemic. This was compared with observed mortality reported each week. Information on deaths registered was obtained from death certificates. Ethnicity was obtained from hospital records linked to deaths data.ResultsEarly in the pandemic, excess deaths exceeded official reported COVID-19 deaths every week. Throughout the pandemic there were stark inequalities in excess death rates. Based on data from 21 March 2020 to 9 April 2021, people living in the most deprived areas in England experienced more excess (1.21 times; 95% CI 1.21-1.22) compared with people living in the least deprived areas (1.17; 1.16-1.18). Black (1.56; 1.53-1.58) and Asian groups (1.55; 1.53-1.56) experienced more excess than the White group (1.16; 1.16-1.17). There was wide variation between English regions.ConclusionsReporting overall excess mortality early in the pandemic is important to inform policy makers and public about the true scale of the death toll when coding is inconsistent and developing. This approach has highlighted the large increases in already established inequalities in mortality. It provides rapid surveillance of developing disparities for national and local decision makers. It has been used to inform policy around reducing disparities and to revise messaging to encourage hospital attendance for non- COVID-19 health problems.Key messages Excess deaths from all causes is a robust measure of overall impact, unaffected by coding consistency.COVID-19 has dramatically worsened established inequalities between ethnic groups and deprivation groups.

Evaluating the effectiveness and cost effectiveness of the \u2018strengthening families, strengthening communities\u2019 group-based parenting programme: study protocol and initial insights

BackgroundUp to 20% of UK children experience socio-emotional difficulties which can have serious implications for themselves, their families and society. Stark socioeconomic and ethnic inequalities in children’s well-being exist. Supporting parents to develop effective parenting skills is an important preventive strategy in reducing inequalities. Parenting interventions have been developed, which aim to reduce the severity and impact of these difficulties. However, most parenting interventions in the UK focus on early childhood (0–10 years) and often fail to engage families from ethnic minority groups and those living in poverty. Strengthening Families, Strengthening Communities (SFSC) is a parenting programme designed by the Race Equality Foundation, which aims to address this gap. Evidence from preliminary studies is encouraging, but no randomised controlled trials have been undertaken so far.Methods/designThe TOGETHER study is a multi-centre, waiting list controlled, randomised trial, which aims to test the effectiveness of SFSC in families with children aged 3–18 across seven urban areas in England with ethnically and socially diverse populations. The primary outcome is parental mental well-being (assessed by the Warwick-Edinburgh Mental Well-Being Scale). Secondary outcomes include child socio-emotional well-being, parenting practices, family relationships, self-efficacy, quality of life, and community engagement. Outcomes are assessed at baseline, post intervention, three- and six-months post intervention. Cost effectiveness will be estimated using a cost-utility analysis and cost-consequences analysis. The study is conducted in two stages. Stage 1 comprised a 6-month internal pilot to determine the feasibility of the trial. A set of progression criteria were developed to determine whether the stage 2 main trial should proceed. An embedded process evaluation will assess the fidelity and acceptability of the intervention.DiscussionIn this paper we provide details of the study protocol for this trial. We also describe challenges to implementing the protocol and how these were addressed. Once completed, if beneficial effects on both parental and child outcomes are found, the impact, both immediate and longer term, are potentially significant. As the intervention focuses on supporting families living in poverty and those from minority ethnic communities, the intervention should also ultimately have a beneficial impact on reducing health inequalities.Trial registrationProspectively registered Randomised Controlled Trial ISRCTN15194500.

A spatial analysis of lime resources and their potential for improving soil magnesium concentrations and pH in grassland areas of England and Wales

Magnesium (Mg) is essential for animal health. Low Mg status (hypomagnesaemia) can be potentially fatal in ruminants, like cattle and sheep, and is widespread in Europe with economic impacts on farming. The application of Mg-rich agricultural lime products can help to ensure pasture forage consumed by animals contains sufficient Mg and, in areas of low pH, has the dual benefit of reducing soil acidity to levels best suited for grass production. This aim of this study was to determine if Mg-rich lime products could be used in a more effective manner in agricultural production systems. Potential resources of carbonate rocks (limestone, dolostone and chalk) in the UK, and their Mg:Ca status were identified, using datasets from the British Geological Survey (BGS). These data were combined with the locations of agricultural lime quarries, and areas where soils are likely to be deficient in Mg and/or require liming. Areas of potential demand for Mg-rich agricultural lime include areas in south east Wales, the Midlands and North East England. Although, areas where this may be an effective solution to low soil Mg values are restricted by the availability of suitable products. Conversely, areas of low soil pH in England and Wales are often found close to quarries with the ability to supply high Ca limes, suggesting that the low rates of lime use and liming is not due to supply factors. This study provides information that can help to guide on-farm decision making for use of Mg-rich and other lime resources. This could be used in conjunction with other options to reduce risks of Mg deficiency in livestock, and improve soil pH.

Widening life expectancy inequalities across small areas of England

The UK has a long tradition of investigating geographical differences in mortality going back to the middle of the 19th century. William Farr, the 19th century pioneer of scientific analysis of vital statistics data, regarded identification and investigation of unhealthy districts as a way to help inform policies to reduce social inequalities in mortality.1 The persistence of pronounced geographical inequalities in the UK and their widening over the past 30–40 years has been noted on many occasions.

Are dietary patterns in early childhood associated with alcohol consumption at the age of 17 years? Analysis of data from the Avon Longitudinal Study of Parents and Children (ALSPAC) prospective cohort study.

To examine the relationship between a posteriori dietary patterns in early childhood and alcohol consumption in adolescence. Data were obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC) prospective cohort study. Dietary information was obtained using FFQ at the age of 3 and 7 years. The association between dietary patterns, derived using principal components analysis and the Alcohol Use Disorders Identification Test (AUDIT) scores (to assess harmful intake) and frequency of alcohol consumption at the age of 17 years were examined. Secondary analysis considered sugar intake as a percentage of total energy intake. Women who gave birth between 1 April 1991 and 31 December 1992 in the Avon area in southwest England were eligible for the ALSPAC cohort study. Totally, 14541 pregnancies were enrolled in ALSPAC during its initial recruitment phase. For this analysis, complete data were available for between 3148 and 3520 participants. Adherence to the 'healthy' dietary pattern at both 3 and 7 years of age was positively associated with consuming more than one alcoholic drink per week at 17 years of age, whilst adherence to the 'traditional' dietary pattern at both ages was protective of harmful alcohol intake at 17 years of age. Sugar intake was not associated with either alcohol outcome after adjustment for ethnicity, maternal level of education, parental social class and maternal AUDIT score. For the population studied, changes to diet in early childhood are unlikely to have an impact on harmful alcohol use in adolescence given the lack of consistency across the results.

Spatial Risk Factors for Pillar 1 COVID-19 Excess Cases and Mortality in Rural Eastern England, UK.

Understanding is still developing about spatial risk factors for COVID‐19 infection or mortality. This is a secondary analysis of patient records in a confined area of eastern England, covering persons who tested positive for SARS‐CoV‐2 through end May 2020, including dates of death and residence area. We obtained residence area data on air quality, deprivation levels, care home bed capacity, age distribution, rurality, access to employment centers, and population density. We considered these covariates as risk factors for excess cases and excess deaths in the 28 days after confirmation of positive Covid status relative to the overall case load and death recorded for the study area as a whole. We used the conditional autoregressive Besag—York–Mollie model to investigate the spatial dependency of cases and deaths allowing for a Poisson error structure. Structural equation models were applied to clarify relationships between predictors and outcomes. Excess case counts or excess deaths were both predicted by the percentage of population age 65 years, care home bed capacity and less rurality: older population and more urban areas saw excess cases. Greater deprivation did not correlate with excess case counts but was significantly linked to higher mortality rates after infection. Neither excess cases nor excess deaths were predicted by population density, travel time to local employment centers, or air quality indicators. Only 66% of mortality was explained by locally high case counts. Higher deprivation clearly linked to higher COVID‐19 mortality separate from wider community prevalence and other spatial risk factors.

Listening to further education students’ perspectives: examining student voice practice through the lens of auto-driven photo elicitation

ABSTRACT This study explores student voice practice from a student’s viewpoint. Within England, United Kingdom (UK) student voice initiatives can manifest themselves in many ways, for example: surveys, councils, governors, representative groups, committees and student bodies such as the National Union of Students. The young people that took part in this study were between 16 and 20 years old. In total, 57 students took part in the research: 22 females and 35 males. The students were from a variety of socio-economic backgrounds. The setting was a Further Education College in an urban area of Central England, which serves students from areas of social and economic disadvantage. The project employed a mixed methods research design, with Bourdieu’s notions of social capital applied to the analysis. Students took part in focus groups and auto-driven photo-elicitation, followed by semi-structured interviews. The data was analysed thematically utilising an interpretivist approach. The themes demonstrated a student body that was largely dismissive of formal channels of student voice practice, preferring different modes of interaction with their teachers. The findings have implications for student voice practice across England and offer insight into how young people may better be enabled to shape their educational experiences.

Geographic location and other determinants of patient decision-making to decline chemotherapy in advanced breast cancer.

111 Background: Much work has been done to explore how social determinants of health are associated with disparities in the use of chemotherapy for breast cancer. We used a large national registry to explore whether patient decision-making to accept or decline chemotherapy varies geographically across the United States. Methods: This analysis used the National Cancer Database to study decision-making in patients diagnosed with advanced breast cancer (AJCC clinical stage III-IV) between 2004-2017. We identified patients recommended chemotherapy by their physicians, but who declined treatment. We performed multivariate logistic regression modeling to explore variables associated with the decision to decline chemotherapy. Results: A total of n = 167,647 patients with stage III-IV breast cancer were included. After controlling for age, race, ethnicity, Charlson/Deyo comorbidity scoring, receptor status, histology, grade, patient education, insurance status, and facility type, geographic region was found to be significantly associated with the decision to either accept or decline chemotherapy (p < 0.001). Patients in the New England area (i.e. CT, MA, ME, NH, RI and VT) exhibited the highest rate of refusal of chemotherapy (9.3%). In contrast, patients in East South Central states (i.e. AL, KY, MS, TN) were the least likely to decline chemotherapy at 5.5% rate of refusal (OR 0.55, 95% CI: 0.47-0.66, p < 0.001). Rates of refusal were lower for patients with TNBC at 4.1% versus 7.7% in those with HR+/HER2 tumors. Patients aged > 70 had increased odds of declining chemotherapy (OR 9.30, 95% CI: 8.17-10.59, p < 0.001) compared to patients < 50. Race and level of education were not associated with patient decision-making in this cohort, however, Hispanics had lower odds (OR 0.70, 95% CI: 0.60-0.82, p < 0.001) of refusing chemotherapy as compared to Non-Hispanics. Patients with higher comorbidity were also more likely to decline chemotherapy (p < 0.05). As compared to the uninsured, Medicare-insured (OR 0.69, 95% CI: 0.60-0.80, p < 0.001), Medicaid-insured (OR 0.65, 95% CI: 0.56-0.76, p < 0.001) and privately-insured patients (OR 0.39, 95% CI: 0.33-0.44, p < 0.001) were less likely to decline chemotherapy. Lastly, patients treated at academic institutions (OR 0.90, 95% CI: 0.81-0.99, p = 0.029) were less likely to decline chemotherapy compared to those in community cancer programs. Conclusions: This study showed that after adjusting for known social determinants of health, there was a significant difference in rates of refusal of recommended chemotherapy by geographic region, with highest refusal rates in New England states. Of interest, Hispanic ethnicity was associated with lower likelihood to decline chemotherapy, while uninsured status was associated with increased refusal. Researching this geographic differential further will help improve efficacy of care delivery in patients with cancer.

Intended and unintended consequences of the implementation of minimum unit pricing of alcohol in Scotland: a natural experiment

Background Scotland was the first country to implement minimum unit pricing for alcohol nationally. Minimum unit pricing aims to reduce alcohol-related harms and to narrow health inequalities. Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. This study comprised three components. Objectives This study comprised three components assessing alcohol consumption and alcohol-related attendances in emergency departments, investigating potential unintended effects of minimum unit pricing on alcohol source and drug use, and exploring changes in public attitudes, experiences and norms towards minimum unit pricing and alcohol use. Design We conducted a natural experiment study using repeated cross-sectional surveys comparing Scotland (intervention) and North England (control) areas. This involved comparing changes in Scotland following the introduction of minimum unit pricing with changes seen in the north of England over the same period. Difference-in-difference analyses compared intervention and control areas. Focus groups with young people and heavy drinkers, and interviews with professional stakeholders before and after minimum unit pricing implementation in Scotland allowed exploration of attitudes, experiences and behaviours, stakeholder perceptions and potential mechanisms of effect. Setting Four emergency departments in Scotland and North England (component 1), six sexual health clinics in Scotland and North England (component 2), and focus groups and interviews in Scotland (component 3). Participants Research nurses interviewed 23,455 adults in emergency departments, and 15,218 participants self-completed questionnaires in sexual health clinics. We interviewed 30 stakeholders and 105 individuals participated in focus groups. Intervention Minimum unit pricing sets a minimum retail price based on alcohol content, targeting products preferentially consumed by high-risk drinkers. Results The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented. The odds ratio for illicit drug consumption following minimum unit pricing was 1.04 (95% confidence interval 0.88 to 1.24; p = 0.612). Concerns about harms, including crime and the use of other sources of alcohol, were generally not realised. Stakeholders and the public generally did not perceive price increases or changed consumption. A lack of understanding of the policy may have caused concerns about harms to dependent drinkers among participants from more deprived areas. Limitations The short interval between policy announcement and implementation left limited time for pre-intervention data collection. Conclusions Within the emergency departments, there was no evidence of a beneficial impact of minimum unit pricing. Implementation appeared to have been successful and there was no evidence of substitution from alcohol consumption to other drugs. Drinkers and stakeholders largely reported not noticing any change in price or consumption. The lack of effect observed in these settings in the short term, and the problem-free implementation, suggests that the price per unit set (£0.50) was acceptable, but may be too low. Our evaluation, which itself contains multiple components, is part of a wider programme co-ordinated by Public Health Scotland and the results should be understood in this wider context. Future work Repeated evaluation of similar policies in different contexts with varying prices would enable a fuller picture of the relationship between price and impacts. Trial registration Current Controlled Trials ISRCTN16039407. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.

Family Functioning as a Protective Factor for Sexual Risk Behaviors Among Gender Minority Adolescents.

Gender minority (GM) youth are more likely to engage in sexual behaviors that increase risk of exposure to sexually transmitted infections, including HIV. However, family functioning may be protective against sexual risk taking. We characterized longitudinal associations between family functioning (family communication and family satisfaction) and sexual risk behaviors across two years in a community sample of 30 GM adolescents, ages 13-17years. Participants were purposively recruited from community-based venues, through social media, and peer referrals throughout the New England area and completed surveys every 6 months, with measures of family functioning, sexual risk behaviors, risk factors (depressive and anxious symptoms, perceived stress related to parents), and protective factors (social support, gender-related pride, and community connectedness). Results indicated that higher levels of family communication, improved family satisfaction, and increased social support were protective for sexual risk taking, in general, and specifically for condom use for anal/vaginal sex. In contrast, increased depressive symptoms were associated with lower likelihood of anal/vaginal condom use. Associations between family functioning and sexual risk taking were not attenuated by adding risk and protective factors to the model; thus, these factors did not explain the observed associations between family functioning and sexual risk taking. These findings suggest improved family functioning, greater social support, and lower depressive symptoms are associated with reduced sexual risk taking among gender minority youth, thus making these factors an important target for future prevention efforts.

DISCOVERIES FROM THE USE OF POLYGENIC SCORES IN AN ELECTRONIC HEALTH RECORD RESEARCH SETTING

The causes and consequences of health inequalities (and their implications for research and practice) have not, it is fair to say, been a notable feature of the body of work that we refer to as social pharmacy. By contrast, the previous three decades have witnessed a burgeoning number of empirical studies, numerous reviews, and growing political awareness about the social determinants of health inequalities. The field of epidemiology and public health, focusing on health inequalities, has risen in prominence with a finding that an individual's social position (whether this is measured by social class, education, or deprivation) profoundly shapes their health outcomes. To illustrate this using deprivation as a marker of social position, the recent Global Burden of Disease study showed that males who lived in the most deprived areas of England in 2013 could expect to have a life expectancy which was 8.2 years shorter than those living in the least deprived areas. If we were to look at social class or education, we would also see wide differences in health outcomes. There are, of course, huge inequalities in health outcomes when we compare health outcomes within and between different countries. For those who want to know more about this literature, there are numerous reviews.

Area level deprivation and monthly COVID-19 cases: The impact of government policy in England

This paper aims to understand the relationship between area level deprivation and monthly COVID-19 cases in England in response to government policy throughout 2020. The response variable is monthly reported COVID-19 cases at the Middle Super Output Area (MSOA) level by Public Health England, with Index of Multiple Deprivation (IMD), ethnicity (percentage of the population across 5 ethnicity categories) and the percentage of the population older than 70 years old and time as predictors. A GEE population-averaged panel-data model was employed to model trends in monthly COVID-19 cases with the population of each MSOA included as the exposure variable. Area level deprivation is significantly associated with COVID-19 cases from March 2020; however, this relationship is reversed in December 2020. Follow up analysis found that this reversal was maintained when controlling for the novel COVID-19 variant outbreak in the South East of England. This analysis indicates that changes in the role of deprivation and monthly reported COVID-19 over time cases may be linked to two government policies: (1) the premature easing of national restrictions in July 2020 when cases were still high in the most deprived areas in England and (2) the introduction of a regional tiered system in October predominantly in the North of England. The analysis adds to the evidence showing that deprivation is a key driver of COVID-19 outcomes and highlights the unintended negative impact of government policy.

Sexualized drug use and specialist service experience among MSM attending urban and rural sexual health clinics in England and Scotland.

Background: To date, evidence on whether sexualized drug use (SDU) and chemsex occur less frequently in rural compared to urban areas in Britain has been conflicting. This study aimed to better measure and understand whether attending urban versus rural sexual health clinics in the United Kingdom was associated with a difference in men who have sex with men’s (MSM) experience of SDU or their access to SDU support. Methods: Men from 29 sexual health services across England and Scotland were recruited by self-completing a waiting room survey. Results: A total of 2655 men (864 MSM) took part. There was no statistically significant difference in recent SDU or chemsex identified in MSM attending rural compared to urban clinics. Gamma-Hydroxybutyrate/Gamma-Butyrolactone (GHB/GBL) was the most commonly reported chemsex drug used in a sexual setting, with equal prevalence of use in urban and rural MSM attendees. Distance travelled for SDU was not significantly different for rural compared to urban MSM. Rural MSM reported a higher rate of unmet need for SDU specific services, although this difference was not statistically significant. Conclusion: Within this sample of MSM, there were no significant differences in sexualized drug use behaviours between those attending rural compared to urban sexual health settings.