Southwest England Research Articles

Demographic and socioeconomic predictors of religious/spiritual beliefs and behaviours in a prospective cohort study (ALSPAC) in Southwest England: Results from the offspring generation

Background We explored associations between possible demographic and socioeconomic causes of religious/spiritual beliefs and behaviours (RSBB) in the offspring generation of the Avon Longitudinal Study of Parents and Children (ALSPAC). Methods We examined approximately 4,450 offspring aged 28 years with RSBB data from a prospective birth cohort study (ALSPAC) in Southwest England. Three RSBB outcome measures were assessed: religious belief (belief in God/a divine power; yes/not sure/no), religious affiliation (Christian/none/other) and religious attendance (frequency of attendance at a place of worship). We explored age- and sex-adjusted associations between 35 demographic and socioeconomic exposures and each of the three RSBB outcomes using multinomial regression. Exposure-sex interactions were also examined. Results Some sociodemographic factors were associated with RSBB in this cohort; for instance, being female and from an ethnicity other than White were associated with increased religiosity across all domains. For many other exposures, however, associations were frequently null or inconsistent, often depending on the specific exposure and outcome combination. As an example, higher educational attainment was associated with higher rates of religious attendance, but not with religious belief or affiliation; in contrast, higher income was associated with lower levels of religiosity. No consistent interactions between sex and the exposures on RSBB were found. Effect sizes were also rather weak, with most pseudo-R 2 values below 0.5% and a maximum of 1.2%. Conclusions The results highlight that several demographic and socioeconomic factors are associated with RSBB in this cohort. However, the number of these associations, and their magnitude, is smaller than comparable results from the parental generation of these offspring, suggesting that patterns of sociodemographic factors associated with RSBB differ between these generations. In addition to describing these associations, this paper will help inform future studies using these data, particularly regarding the choice of potential sociodemographic confounders.

‘The Wild West of England’: Enclosure, Stag-Hunting, and the Creation of New Popular Perceptions of Exmoor in the Nineteenth Century

ABSTRACT Recent research emphasises parallels between agrarian enclosure campaigns in eighteenth and nineteenth century Britain and Ireland, and neo-colonial discourses. Both used the ‘wasteful’ under-exploitation of land by indigenous populations as moral justifications for its appropriation for capitalist agriculture. Focusing on reclamation campaigns on Exmoor, a former royal forest in south-west England, sold by the Crown in 1818, this article shows how these discourses were displaced by emergent defences of undeveloped ‘wildness’, advanced in sustained media campaign by advocates of stag hunting. Although they pitted ‘wildness’ against ‘civilised’ agriculture, the article argues that this was an alternative discourse of modernity. 1

Neighbourhood North: maximum gain, minimum pain – transformational office redevelopment

This article explores the project aims, challenges, solutions and lessons learned in redeveloping an existing 1980s quayside office block in southwest England. A full-height side extension introduced a double-height atrium entrance and unlocked the full potential of the office floorplates. New, larger windows were added in the existing facades, which improved the building's environmental performance, including more daylight and reduced heat loss. The client has a strong sustainability ethic and cross-laminated timber floor slabs were included in the design, which aspires to achieve BREEAM Outstanding accreditation. The project achieved an overall SCORS rating of A+, bordering on A++, at 53kg/CO2e/m2, despite the extension itself having a SCORS rating of F.

Qualitative evaluation of digital vending machines to improve access to STI and HIV testing in South West England: using a Person-Based Approach

ObjectivesTo report the development, implementation, acceptability and feasibility of vending machines offering HIV and sexually transmitted infection (STI) testing kits.DesignA qualitative study using the Person-Based Approach with patient and public...

Clinical effectiveness of a modified muscle sparing posterior technique compared with a standard lateral approach in hip hemiarthroplasty for displaced intracapsular fractures (HemiSPAIRE): a multicenter, parallel-group, randomized controlled trial

ObjectivesAssess the effect of a modified muscle sparing posterior approach; SPAIRE (Save Piriformis and Internus, Repairing Externus), in hip hemiarthroplasty for displaced intracapsular fractures on postoperative mobility and function compared...

Using GIS for flood hazard assessment

ABSTRACT When evaluating environmental challenges such as vulnerability to natural hazards, it is important to consider both the physical exposure as well as the socio-demographic characteristics of a population. Human populations and their characteristics vary considerably over space and time. This paper introduces and evaluates an open-source resource that has been developed to introduce students in higher education to the quantitative skills required to evaluate pressing social and environmental challenges. It utilises census and hazard data within QGIS and R for a flood risk example in southwest England. A standalone online practical resource supports students to obtain, prepare, visualise and analyse geospatial data with reference to population characteristics. Within the exemplar provided, it is determined that there is a significant (p < 0.01) but small difference in the population exposed to flood risk based on socio-economic classification within SW England. The resource is reviewed following student feedback as well as a discussion for its use as a possible outreach tool.

Development and implementation of an online intervention and embedded decision aid to support self-management of acne vulgaris: qualitative interviews with healthcare professionals.

Acne is common and has a significant impact on quality of life. Topical treatments are first-line and effective, but non-adherence is common due to slow onset of action, or lack of advice on how to manage side effects. The Acne Care Online programme is developing an online intervention to support acne self-management and help-seeking. This project aims to explore experiences and views of healthcare professionals (HCPs) treating acne to assess the acceptability and feasibility of implementing this intervention and embedded decision aid in practice. This qualitative study recruited HCPs working in general practice. Email invitations were sent to eight research-active practices in Southwest England, and snowball sampling was used. Purposive sampling was used to seek diverse participants. Semi-structured virtual interviews were conducted, audio-recorded, and transcribed. Data were explored using thematic analysis. Nine interviews were conducted, including seven GPs, one nurse, and one pharmacist. Findings highlighted challenges faced by HCPs managing acne in time-limited consultations, particularly around patients' limited understanding of effective treatments, frequent requests from patients for non-first-line treatments, treatment non-adherence, and addressing psychosocial impact. The intervention and embedded decision aid were perceived as beneficial in addressing these challenges, improving shared decision making, and providing a reliable resource for patients. Interviewees suggested integrating the intervention into electronic practice templates for effective implementation. HCPs were positive about the potential for the intervention to be implemented as a useful tool in practice. Potential implementation barriers need to be considered, such as making the intervention quick to access in time-limited consultations.

Dietitians’ perspectives on clinical pathways and practice in relation to the dietary management of irritable bowel syndrome in the UK: A qualitative study

Irritable bowel syndrome (IBS) is a chronic and relapsing gastrointestinal condition which negatively impacts quality of life(1). Dietary triggers are common and dietary management is central to the IBS treatment pathway with dietitians being the main education providers for patients(2). The aim of this study was to explore the perceptions of dietitians towards current practices in IBS services in clinical settings across the UK.Qualitative semi-structured interviews were undertaken to explore current practices, barriers, and facilitators to dietetic practice and expected treatment outcomes. Eligible participants were dietitians specialising in IBS and working in the National Health System (NHS) in the UK. Interviews were held virtually. Audio was recorded and transcribed following intelligent transcription. Data were analysed using template analysis (3).Thirteen dietitians (n=12 female) specialising in gastroenterology consented to participate in the study. Dietitians were working in various NHS Trusts across the country (Southeast England n=3; Southwest England n=3; Northwest England n=2; Northeast England n=1; West Midlands n=1; Southwest Wales n=1 and Southcentral Scotland n=2). Ten out of 13 dietitians had more than five years of experience in IBS management. Three main themes emerged: 1) Dietetic services as part of IBS referral pathways; 2) Practices in relation to dietetic services and 3) Implications of services on patients’ expectations and feelings. Each main theme had subthemes to facilitate the description and interpretation of data. The increasing number of IBS referrals to dietitians and the need for accurate and timely IBS diagnosis and specialist IBS dietitians was reported, alongside the use of digital innovation to facilitate practice and access to dietetic care. The use of Internet as a source of (mis)information by patients and the limited time available for educating patients were identified as potential barriers to dietetic practice. Dietitians follow a patient-centred approach to dietary counselling and recognise the negative implications of perceived IBS-related stigma by patients on their feelings and treatment expectations.The study identified areas and practices which can facilitate access to dietetic services and patient- centred care in IBS management as outlined in guidelines (4).

The Northeast of England in the era of the Wars of the Roses (using the example of the Paston family)

The subject of the study is the participation of the English small-scale provincial nobility in the events of the Wars of the Roses (1455-1485) and their behavior patterns in the context of a dynastic conflict, using the example of the fate of John Paston from Norfolk County (northeast of England). Special attention is paid to how the relationship between the average nobleman and his neighbors was built, the circle of his acquaintances, the degree of involvement in national politics, personal conflicts and motives. Both the general patterns characteristic of the fate of most representatives of the privileged class of the XV century are considered, as well as the specifics that distinguish the region specifically studied and the personalities of interest to us in comparison with data from other counties (primarily the south-west of England). The main source is the fundamental family archive "Letters of the Pastors", which contains invaluable information on the English history of the period we are interested in. The research is based on the principles of historicism and scientific objectivity and is based on the problem-chronological principle. Analytical, comparative historical and dialectical methods are used in the analysis of historical sources. Due to the fact that the study is built around the biography of a particular person, the events of the epoch we are interested in are considered from the perspective of microhistory. Within the framework of the study, the working hypothesis developed by the author in other articles ("John Trevelyan and the Wars of the Roses", "English provincial Nobility and the Wars of the Roses", "The political struggle of the era of the Wars of the Roses in the light of English parliamentary legislation") on the evolution of the policy of the royal power in relation to the provincial nobility is being tested. At the initial stage of the Wars of the Roses, the Lancastrian party is the first to move to form the ranks of its supporters in the counties, which, using the example of Norfolk, leads to a conflict between John Paston and Lord Molanes, a prominent supporter of the Lancaster dynasty. The fact that Paston did not become an active Yorkist turned into difficulties for him at the next stage, when King Edward IV switched to a policy of reconciliation of warring factions, which is why the nobles, who remained neutral during the conflict, found themselves at enmity with both supporters of the Yorks and former Lancastrians reconciled with the new dynasty.

Living in a post‐industrial landscape: repeated patterns of genetic divergence in brown trout (Salmo trutta L.) across the British Isles

AbstractAimThe British Isles have been worked for millennia to extract metal ores to feed industrial development, leaving a legacy of mine water pollution that continues to impact freshwater communities in many regions. Brown trout (Salmo trutta L.) have long been observed to persist in these metal‐impacted systems as apex predators, with previous studies showing a small number of impacted populations to be highly genetically divergent. We sought to understand the scale of genetic diversity across regions and the repeatability of genetic divergence in trout populations affected by metal pollution.LocationWe examined four mine water‐impacted regions across the British Isles: west Wales, northeast England, southwest England and southeast Ireland.MethodsWe employed a panel of 95 SNP loci to screen 1236 individuals from 71 sites representing paired metal‐impacted and clean sites from across the four regions. From these, we obtained diversity statistics, assessed genetic structuring of populations and modelled historical demographic scenarios to understand which factors most credibly explain genetic variation in divergent populations.ResultsWe evidenced hierarchical population structure in the regions studied, in line with expectations from phylogeographic history. However, in a hierarchical analysis of genetic structuring the first level of differentiation was driven by the divergence of the metal‐impacted trout of Cornwall in southwest England. Within regions we observed reduced genetic diversity and repeated patterns of local genetic sub‐structuring between paired samples from metal‐impacted and relatively clean sites. Demographic history analyses suggested the timing of these splits to be relatively recent and to be associated with periods of peak mining activity.Main conclusionsOur findings demonstrate distinct patterns of genetic isolation and reduced diversity arising from legacy pollution in freshwater ecosystems, with impacts being most apparent where both chemical pollution and physical barriers are present. Management should focus on the amelioration of mine water wash‐out and the removal of barriers to fish movement to safeguard genetic diversity in impacted populations.

Genetic differentiation at extreme latitudes in the socially plastic sweat bee Halictus rubicundus.

The sweat bee Halictus rubicundus is an important pollinator with a large latitudinal range and many potential barriers to gene flow. Alongside typical physical barriers, including mountain ranges and oceans, the climate may also impose restrictions on gene flow in this species. The climate influences voltinism and sociality in H. rubicundus, which is bivoltine and can nest socially at warmer lower latitudes but tends to be univoltine and solitary in the cooler north. Variation in voltinism could result in phenological differences, potentially limiting gene flow, but a previous study found no evidence for this in H. rubicundus populations in mainland Britain. Here we extend the previous study to consider populations of H. rubicundus at extreme northern and southern latitudes in the UK. We found that bees from a population in the far north of Scotland were genetically differentiated from bees collected in Cornwall in the south-west of England. In contrast, bees collected across the Irish Sea in Northern Ireland showed slight genetic overlap with both the Scottish and Cornish bees. Our results suggest that when populations at extreme latitudes are considered, phenology and the climate may act alongside physical barriers such as the Scottish Highlands and the Irish Sea to restrict gene flow in H. rubicundus. We discuss the implications of our results for local adaptation in the face of rapidly changing selection pressures which are likely under climate change.

Air and Noise Pollution Exposure in Early Life and Mental Health From Adolescence to Young Adulthood

Growing evidence associates air pollution exposure with various psychiatric disorders. However, the importance of early-life (eg, prenatal) air pollution exposure to mental health during youth is poorly understood, and few longitudinal studies have investigated the association of noise pollution with youth mental health. To examine the longitudinal associations of air and noise pollution exposure in pregnancy, childhood, and adolescence with psychotic experiences, depression, and anxiety in youths from ages 13 to 24 years. This cohort study used data from the Avon Longitudinal Study of Parents and Children, an ongoing longitudinal birth cohort founded in 1991 through 1993 in Southwest England, United Kingdom. The cohort includes over 14 000 infants with due dates between April 1, 1991, and December 31, 1992, who were subsequently followed up into adulthood. Data were analyzed October 29, 2021, to March 11, 2024. A novel linkage (completed in 2020) was performed to link high-resolution (100 m2) estimates of nitrogen dioxide (NO2), fine particulate matter under 2.5 μm (PM2.5), and noise pollution to home addresses from pregnancy to 12 years of age. Psychotic experiences, depression, and anxiety were measured at ages 13, 18, and 24 years. Logistic regression models controlled for key individual-, family-, and area-level confounders. This cohort study included 9065 participants who had any mental health data, of whom (with sample size varying by parameter) 51.4% (4657 of 9051) were female, 19.5% (1544 of 7910) reported psychotic experiences, 11.4% (947 of 8344) reported depression, and 9.7% (811 of 8398) reported anxiety. Mean (SD) age at follow-up was 24.5 (0.8) years. After covariate adjustment, IQR increases (0.72 μg/m3) in PM2.5 levels during pregnancy (adjusted odds ratio [AOR], 1.11 [95% CI, 1.04-1.19]; P = .002) and during childhood (AOR, 1.09 [95% CI, 1.00-1.10]; P = .04) were associated with elevated odds for psychotic experiences. Pregnancy PM2.5 exposure was also associated with depression (AOR, 1.10 [95% CI, 1.02-1.18]; P = .01). Higher noise pollution exposure in childhood (AOR, 1.19 [95% CI, 1.03-1.38]; P = .02) and adolescence (AOR, 1.22 [95% CI, 1.02-1.45]; P = .03) was associated with elevated odds for anxiety. In this longitudinal cohort study, early-life air and noise pollution exposure were prospectively associated with 3 common mental health problems from adolescence to young adulthood. There was a degree of specificity in terms of pollutant-timing-outcome associations. Interventions to reduce air and noise pollution exposure (eg, clean air zones) could potentially improve population mental health. Replication using quasi-experimental designs is now needed to shed further light on the underlying causes of these associations.

A large cryptosporidiosis outbreak associated with an animal contact event in England: a retrospective cohort study, 2023.

Development of gastrointestinal illness after animal contact at petting farms is well described, as are factors such as handwashing and facility design that may modify transmission risk. However, further field evidence on other behaviours and interventions in the context of Cryptosporidium outbreaks linked to animal contact events is needed. Here, we describe a large outbreak of Cryptosporidium parvum (C. parvum) associated with a multi-day lamb petting event in the south-west of England in 2023 and present findings from a cohort study undertaken to investigate factors associated with illness. Detailed exposure questionnaires were distributed to email addresses of 647 single or multiple ticket bookings, and 157 complete responses were received. The outbreak investigation identified 23 laboratory-confirmed primary C. parvum cases. Separately, the cohort study identified 83 cases of cryptosporidiosis-like illness. Associations between illness and entering a lamb petting pen (compared to observing from outside the pen; odds ratio (OR)=2.28, 95 per cent confidence interval (95% CI) 1.17 to 4.53) and self-reported awareness of diarrhoeal and vomiting disease transmission risk on farm sites at the time of visit (OR=0.40, 95% CI 0.19 to 0.84) were observed. In a multivariable model adjusted for household clustering, awareness of disease transmission risk remained a significant protective factor (adjusted OR (aOR)=0.07, 95% CI 0.01 to 0.78). The study demonstrates the likely under-ascertainment of cryptosporidiosis through laboratory surveillance and provides evidence of the impact that public health messaging could have.

Compound mortality impacts from extreme temperatures and the COVID-19 pandemic

Extreme weather and coronavirus-type pandemics are both leading global health concerns. Until now, no study has quantified the compound health consequences of the co-occurrence of them. We estimate the mortality attributable to extreme heat and cold events, which dominate the UK health burden from weather hazards, in England and Wales in the period 2020-2022, during which the COVID-19 pandemic peaked in terms of mortality. We show that temperature-related mortality exceeded COVID-19 mortality by 8% in South West England. Combined, extreme temperatures and COVID-19 led to 19 (95% confidence interval: 16–22 in North West England) to 24 (95% confidence interval: 20–29 in Wales) excess deaths per 100,000 population during heatwaves, and 80 (95% confidence interval: 75–86 in Yorkshire and the Humber) to 127 (95% confidence interval: 123–132 in East of England) excess deaths per 100,000 population during cold snaps. These numbers are at least ~2 times higher than the previous decade. Society must increase preparedness for compound health crises such as extreme weather coinciding with pandemics.

Can toll prices changes affect the housing market? The case of the Severn crossing toll removal

PurposeSince 1966, the Severn crossing has been connecting England and Wales. In January 2018, its ownership returned to the UK Government, and this marked the start of a toll-free journey across the two countries and made commuting between the regions more affordable. In this paper, we examine the impact of the toll removal on the property market.Design/methodology/approachWe employ property-level data from the Land Registry and a difference-in-differences (DiD) empirical model for the periods 2016–2018 and 2019–2021 to capture the pre- and post-toll removal dynamics. The DiD estimation allows us to examine the causal relationship between policy changes and property prices.FindingsOur findings suggest that property prices in Newport and Monmouthshire (South East Wales) are positively affected by the policy, which results in a statistically significant increase of 5.8% more than those located in the South West England (Bristol and South Gloucestershire) region in the period 2019–2021. The impact can reach up to 13.1% for properties located in a 10 km radius of the bridge. The results indicate that the toll removal enables the ripple effect across the two markets by reducing commuting costs.Originality/valueThis is the first paper that examines the Severn Crossing case study. Its contribution is significant since we provide empirical evidence on how reduced transportation costs increase property prices in the lowest income region and have the opposite effect on the area with higher incomes and economic activity levels.

Sexual experiences, behaviours and attitudes in the parents in the Avon Longitudinal Study of Parents and Childhood (ALSPAC)

The aim of this data note is to describe the sexual experiences, behaviours, and attitudes data collected from the parent cohorts of the Avon Longitudinal Study of Parents and Children (ALSPAC) over a 30-year period. ALSPAC is an ongoing birth cohort which enrolled 14,541 pregnant women living in Avon, a county of southwest England, with expected dates of delivery between April 1991 and December 1992 inclusive and continues collecting data on these mothers (age range at delivery &lt;16–41 years), their partners (age range at delivery &lt;16–65), and their offspring, so far resulting in 100,000+ phenotype variables. During the index pregnancy the mothers were asked (and at 8 months post-delivery for partners) about their early sexual experiences to identify sexual abuse/assaults and the age at which an event first happened. Both parents were asked also about sexual abuse within a battery of questions identifying Adverse Childhood Events (ACE). Further longitudinal data described here includes satisfaction with sexual and non-sexual sides of their relationship; sexual functioning; and at seven years post-delivery, both parents were asked to describe their sexual orientation as well as the sex of their partners and cohabiting partners. These data provide the ability to compare generational differences between parental sexual behaviours and attitudes with those of their offspring, as well as allowing comparisons with other longitudinal surveys where similar (or identical) information has been collected such as the National Survey of Sexual Attitudes and Lifestyles (NATSAL-3). This paper forms a companion to another data note describing similar data collected on the offspring cohort.

The burden of periprosthetic femoral fractures in England and Wales: Insights from the first two years of data collection in the National Hip Fracture Database and regional variation in care

IntroductionPeriprosthetic femoral fractures (PPFFs) represent an important healthcare problem, with a rising incidence noted due to an increase in the number of arthroplasty surgeries being performed. There is a current lack of national consensus as to how these complex, often frail patients are managed. AimsOur primary aim was to present the epidemiology of PPFFs in England and Wales over the first two years of data collection by the National Hip Fracture Database (NHFD). Secondary aims included how well the NHFD Key Performance Indicators (KPIs) are met for PPFF patients, whether centres reporting a higher burden of PPFF patients are more likely to meet KPIs compared to lower volume centres, and to also identify if regional variation in care for these patients exist. MethodsPatients aged 60 years or over, admitted to any acute hospital in England or Wales with a PPFF within the period 1st January 2020 to 31st December 2021 were included. Fractures were classified using the Vancouver system. The primary outcome of interest was the incidence of PPFF in England and Wales. Secondary outcomes included i) geographical distribution, ii) pattern of injury, iii) treatment received, iv) KPI performance nationally, v) KPI performance by top 5 highest volume hospitals vs the rest, vi) KPI performance by region and vii) KPI performance compared with native hip fracture patients. ResultsA total of 5,566 PPFFs were reported during our study period. A 31 % increase in cases was seen between 2020 and 2021 (2,405 to 3,161). The South-West of England reported the highest burden of PPFFs (14 % of all cases reported in 2021). Vancouver B subtypes were most common around hip replacements (62 %) and C subtype around knee replacements (55 %). A total of 4,598 patients (82.6 %) underwent operative management. There was regional variation in KPI attainment. When compared to KPI attainment for native hip fractures PPFF care under performed in most regions and domains. High volume PPFF centres were not associated with improved attainment of KPIs. ConclusionWe have described the incidence, nature, and management of PPFF at national and regional levels using routinely collected NHFD data. Both numerically and due to case complexity, PPFF are a considerable challenge to patients and health services alike. This epidemiology is not captured by other existing datasets and increased case contribution to the NHFD is encouraged to improve understanding and enable prioritisation and delivery of further care and research.

The cost of keeping patients waiting: retrospective treatment-control study of additional healthcare utilisation for UK patients awaiting elective treatment.

Long waiting times for elective hospital treatments are common in many countries. This study seeks to address a deficit in the literature concerning the effect of long waits on the wider consumption of healthcare resources. We carried out a retrospective treatment-control study in a healthcare system in South West England from 15 June 2021 to 15 December 2021. We compared weekly contacts with health services of patients waiting over 18 weeks for treatment ('Treatments') and people not on a waiting list ('Controls'). Controls were matched to Treatments based on age, sex, deprivation and multimorbidity. Treatments were stratified by the clinical specialty of the awaited hospital treatment, with healthcare usage assessed over various healthcare settings. Wilcoxon signed-rank tests assessed whether there was an increase in healthcare utilisation and bootstrap resampling was used to estimate the magnitude of any differences. A total of 44,616 patients were waiting over 18 weeks (the constitutional target in England) for treatment during the study period. There was an increase (p < 0.0004) in healthcare utilisation for all specialties. Patients in the Cardiothoracic Surgery specialty had the largest increase, with 17.9 [interquartile-range: 4.3, 33.8] additional contacts with secondary care and 17.3 [-1.1, 34.1] additional prescriptions per year. People waiting for treatment consume higher levels of healthcare than comparable individuals not on a waiting list. These findings are relevant for clinicians and managers in better understanding patient need and reducing harm. Results also highlight the possible 'false economy' in failing to promptly resolve long elective waits.

THREE LATE FIFTEENTH- EARLY SIXTEENTH-CENTURY CHAPEL FURNISHINGS BELONGING TO THE EDGCUMBE FAMILY IN CORNWALL

This study documents three chapel furnishings dating from around 1500 belonging to the Edgcumbe family at Cotehele, Cornwall, south-west England, and discusses their survival during the Protestant Reformation and beyond. The textiles were exhibited to the Society of Antiquaries of London by W H St John Hope, FSA and the text of his presentation was published in the Proceedings of the Society in 1912–13. The present article brings together the numerous other historic writings concerning the textiles. Their possible origins are explored and assessed in context with pieces of similar date. Observations of their original making and later changes are recorded, while interpretations by historians of this period are put forward for consideration. The rarity of survival of the textiles and their documented history is acknowledged.

Developing oral health services for people experiencing severe and multiple disadvantage: a case study from Southwest England.

People experiencing severe and multiple disadvantage (SMD) have disproportionately high levels of dental disease and tooth loss but have limited access to dental care. This paper presents an evidence-based case study of co-designing, implementing, evaluating and refining a community dental clinic for people experiencing SMD in the Southwest of England. It shares challenges, lessons, and solutions. Tailored interventions that coordinate flexible and responsive care are important for facilitating dental access for individuals experiencing SMD. Participatory approaches can deliver a range of impacts both on research and service development. No single fixed model of co-design can be applied in service development, and the choice will vary depending on local context, available resources and joint decision making. Through co-design, vulnerable populations such as those with SMD can shape dental services that are more acceptable, appropriate and responsive to their needs. This approach can also ensure long-term sustainability by bridging treatment pathway development and commissioning.