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Background: The Public Health Responsibility Deal (RD) is a public--private partnership in England involving voluntary pledges between government, and business and other public organizations to improve public health. One such voluntary pledge refers to the reduction of trans fatty acids (TFAs) in the food supply in England by either pledging not to use artificial TFAs or pledging artificial TFA removal. This paper evaluates the RD's effectiveness at encouraging signatory organizations to remove artificially produced TFAs from their products. Methods: We analysed publically available data submitted by RD signatory organizations. We analysed their plans and progress towards achieving the TFAs pledge, comparing 2015 progress reports against their delivery plans. We also assessed the extent to which TFAs reductions beyond pre-2011 levels could be attributed to the RD. Results: Voluntary reformulation via the RD has had limited added value, because the first part of the trans fat pledge simply requires organizations to confirm that they do not use TFAs and the second part, that has the potential to reduce use, has failed to attract the participation of food producers, particularly those producing fast foods and takeaways, where most remaining use of artificial TFAs is located. Conclusions: The contribution of the RD TFAs pledges in reducing artificial TFAs from England's food supply beyond pre-2011 levels appears to be negligible. This research has wider implications for the growing international evidence base voluntary food policy, and offers insights for other countries currently undertaking work to remove TFAs from their food supply. [ABSTRACT FROM AUTHOR]

Background Adolescent mental health (AMH) needs in England have increased dramatically and needs exceed treatment availability. This study undertook a comparative assessment of the health and economic return on investment (ROI) of interventions to prevent and treat mental disorders among adolescents (10–19 years) and examined intervention affordability and readiness. Methods Interventions were identified following a review of published and grey literature. A Markov model followed a simulated adolescent cohort to estimate implementation costs and health, education, and economic benefits. Intervention affordability was assessed, comparing annual cost per adolescent with NHS England per capita spending, and an expert panel assessed intervention readiness using a validated framework. Results Over 10- and 80-year horizons, interventions to treat mild anxiety and mild depression were most cost-effective, with the highest individual lifetime ROI (GBP 5822 GBP 1 and GBP 257: GBP 1). Preventing anxiety and depression was most affordable and 'implementation ready' and offered the highest health and economic benefits. A priority package (anxiety and depression prevention; mild anxiety and mild depression treatment) would avert 5 million disability-adjusted life-years (DALYS) and achieve an ROI of GBP 15: GBP 1 over 10 years or 11.5 million DALYs (ROI of GBP 55: GBP 1) over 80 years. Conclusion The economic benefits from preventing and treating common adolescent mental disorders equivalent to 25% of NHS England's annual spending in 2021 over 10 years and 91% over 80 years. Preventing and early treatment for anxiety and depression had the highest ROIs and strong implementation readiness. [ABSTRACT FROM AUTHOR]

Background: This paper proposes that Population Impact Measures (PIMs), the Population Impact Number of Eliminating a Risk Factor over a time period (PIN-ER-t) and the number of events prevented in your population (NEPP), can assist in policy making as they include relevant information which describes the impact or benefits to the population of risk factors and interventions. In this study, we explore the utilization of the indicators from European System of Urban Health Indicators System to produce the two PIMs. Methods: We identified from the indicators list the health determinants, health status and health interventions which can be linked, and searched Medline for evidence of association. We then investigated whether the type of frequency measure available for the indicator match with the measure used in PIMs, and explored data availability for the City of Manchester (UK) as an urban area. Results: Of the 39 indicators relevant to socio-economic factors, health determinants and health status, it was possible to calculate the population impact of a risk factor, i.e. the PIN-ER-t, for only six associations, and the population impact of health interventions, i.e. NEPP, for only one out of the three listed indicators, as the relevant health conditions were not included. Conclusions: The results of this study suggest that if an indicator system is intended to play a part in the policy making process, then the method of presentation to policy-makers should be decided before setting up the system, as it is likely that some indicators which would be essential might not be available. [ABSTRACT FROM AUTHOR]

Background Sustaining public health programmes in the long-term is key to ensuring full manifestation of their intended benefits. Although an increasing interest in sustainability is apparent within the global literature, empirical studies from within the European setting are few. The factors that influence sustainability are generally conceptualized at three levels: programme level, the immediate context and the wider environment. To-date attention has focused primarily on the former two. Using a community-based child injury prevention programme in England as an exemplar, this paper explores the concept of sustainability within the wider policy environment, and considers the impact of this on local programmes. Methods A content review of global and UK national public health policies (1981-2014) relevant to child safety was undertaken. Interviews were held with senior representatives of global and UK agencies involved in developing child safety policy. Results Forty-nine policies were reviewed. The term 'sustain', or its derivatives, featured in 36 (73%) of these. Its' use however, related primarily to conservation of resources rather than continued programme operation. Potential mechanisms for supporting programme sustainability featured within some documents; however, the approach to sustainability was inconsistent between policies and over time. Policy stakeholders identified programme sustainability as relevant to their core business, but its' conceptualization varied according to individual interpretation. Conclusions Programme sustainability is poorly addressed within global and UK-based public health policy. Strengthening a national and international policy focus on sustainability and incorporating sustainability into public health planning frameworks may create a more supportive environment for local programmes. [ABSTRACT FROM AUTHOR]

Background To control the spread of coronavirus disease 2019 (COVID-19), governments are increasingly relying on the public to voluntarily manage risk. Effectiveness is likely to rely in part on how much the public trusts the Government's response. We examined the English public's trust in the Conservative Government to control the spread of COVID-19 after the initial 'crisis' period. Methods We analyzed eight rounds of a longitudinal survey of 1899 smartphone users aged 18–79 in England between October 2020 and December 2021. We fitted a random-effects logit model to identify personal characteristics and opinions associated with trust in the Conservative Government to control the spread of COVID-19. Results Trust was lowest in January 2021 (28%) and highest in March 2021 (44%). Being older, having lower educational attainment and aligning with the Conservative Party were predictors of higher levels of trust. Conversely, being less deprived, reporting that Government communications were not clear and considering that the measures taken by the Government went too far or not far enough were predictors of being less likely to report a great deal or a fair amount of trust in the Government to control the pandemic. Conclusion Trust in the Government's response was found to be low throughout the study. Our findings suggest that there may be scope to avoid losing trust by aligning Government actions more closely with scientific advice and public opinion, and through clearer public health messaging. However, it remains unclear whether and how higher trust in the Government's response would increase compliance with Government advice. [ABSTRACT FROM AUTHOR]

Background Flooding can cause long-term, significant impacts on mental health in affected populations. We explored help-seeking behaviour of households affected by flooding. Methods A cross-sectional analysis was conducted on National Study of Flooding and Health data on households flooded in England in winter 2013/14. Participants (Year 1: n  = 2006; Year 2: n  = 988; Year 3: n  = 819) were asked if they sought help from health services and other sources. Logistic regression was conducted to calculate odds ratios (ORs) of help-seeking in flooded and disrupted participants compared to unaffected, adjusted for a priori confounders. Results The odds of seeking help from any source 1 year after flooding were greater for flooded participants [adjusted OR (aOR): 1.71, 95% confidence interval (CI): 1.19–1.45] and those disrupted by flooding (aOR: 1.92, 95% CI: 1.37–2.68) compared to unaffected participants. This continued in the second year (flooded: aOR 6.24, 95% CI: 3.18–13.34; disrupted: aOR: 2.22, 95% CI: 1.14–4.68), and help-seeking remained greater in flooded than unaffected participants in the third year. Flooded and disrupted participants were particularly likely to seek help from informal sources. Help-seeking was more prevalent amongst participants with mental health outcomes, but a notable proportion of individuals with any mental health outcome did not seek help (Year 1: 15.0%; Year 2: 33.3%; Year 3: 40.3%). Conclusions Flooding is associated with increased demand for formal and informal support, persisting for at least 3 years, and an unmet need for help amongst affected individuals. Our findings should be considered in flood response planning to reduce the long-term adverse health impacts of flooding. [ABSTRACT FROM AUTHOR]

Most American and English cancer patients prefer to die at home. Factors associated with greater likelihood of dying at home have been contradictory in many studies and no studies have compared the effects of factors in different countries. The objective of this paper is to compare the factors affecting place of cancer death in two major cities, New York and London. Methods: We use data on all individuals aged ≥40 dying of cancer in London (59604) and New York City (51 668) in the years 1995 through 1998. The probability of death at home is examined in each city as a function of gender, age group (40-55, 56-64, 65-74, 75+), year, type of cancer, and area socioeconomic status, using multiple logistic regression. Results: Although the probability of death at home is the same in the two cities (∼1 in 5), being female lowers the odds of death at home by ∼7% in London, and raises it by ∼22% in New York. Older age is associated with increased odds of dying at home in New York but decreased odds of dying at home in London. Being in the lowest tercile of socioeconomic status (relative to the highest) lowers the odds of death at home by 22% in London and 39% in New York. Conclusion: Site of death varies significantly by patient and area characteristics in both cities, an understanding, which should be taken account of in future planning of end-of-life care. [ABSTRACT FROM AUTHOR]

Background: This paper presents an analysis of the English experience of setting and monitoring targets during the 1990s. It draws on two studies of the former national public health strategy, ‘Health of the Nation’ (HOTN). Methods: the two evaluations conducted 16 case studies between them, two in each health region in England. Over 250 individual and group interviews were conducted and over 400 documents were analysed. In eight health authorities, an analysis of expenditure was also carried out to determine what impact, if any, HOTN had on resource allocation. Results: Full results are published elsewhere. Lessons for the new strategy are as follows: i) the role of central government is key in ensuring that there is a consistent message across government in support of the health strategy and in fostering the development and dissemination of an evidence-base for public health, ii) The new strategy needs to address the underlying social and structural determinants of health and health inequalities directly, iii) Both studies found widespread support for targets as a helpful way to prioritise and focus efforts. However, national targets must be credible i.e. based on sound and convincing evidence. The development of local targets needs to be encouraged, and process targets should supplement outcomes locally and nationally, iv) The new strategy needs to be communicated widely – to broaden ownership outside the National Health Service, and include the public, v) To sustain momentum and ensure effective implementation, the strategy must be embedded in the performance management framework for health and local authorities, vi) Partnerships between key local agencies to work together for health need to be encouraged, either via a statutory framework or with other incentives. Discussion: The new English strategy, ‘Saving Lives’, is outlined in relation to the development of targets. The wider issues of a target-based approach to health policy include: i) Importance of distinguishing between the objective to ensure that policy is directed towards the achievement of health outcomes, and monitoring progress to ensure that health policy objectives are being achieved, ii) The role of targets as an inspiration as well as or instead of a management tool, iii) A target-based health policy should: set targets which are realistic, achievable and challenging; involve stakeholders; link targets to implementation; consider technical issues e.g. small numbers, availability of data; be based on evidence; express targets in terms of health improvement, iv) Target-based health policies should avoid: perverse incentives; distortion of data; too many targets; target setting without resources, v) The experience from England provides lessons for other European countries introducing a target-based approach to health policy. [ABSTRACT FROM AUTHOR]

This paper examines the relationship between the satisfaction of informal carers with the care delivered to dying people in the last year of life and patient and carer characteristics. A secondary analysis was conducted on a subsample from the Regional Study of Care for the Dying (RSCD) in which bereaved relatives or friends of a random sample of deaths in 1990 in 20 health districts across England were interviewed some 10 months after the death. There were 1,858 informal carers who were close relatives or friends/neighbours of people who died from cancer in this analysis. Results show that highly satisfied carers were those who perceived caring as rewarding (OR=2.31, 95% Cl: 1.04–5.11), those who reported having had no unmet needs while caring for the deceased at home (OR=2.50, 95% Cl: 1.87–3.34), and those who rated their post-bereavement health as excellent (0R=2.61, 95% Cl: 1.70–3.90). Reporting for the deceased who were owner-occupiers was also associated with a high odds ratio for satisfaction (0R=2.52, 95% Cl: 1.37–4.61). Factors such as the patient's duration of functional limitation, the duration of confusion and psychological symptoms, and the carer's strength of religious faith were also found to predict satisfaction but to a lesser extent. Health planners and managers should be aware that informal carers' overall satisfaction with health and social services is predicted by carer and patient attributes. [ABSTRACT FROM AUTHOR]

Background: In assigning responsibility for obesity prevention a distinction may be drawn between who is responsible for the rise in obesity prevalence ('backward-looking responsibility'), and who is responsible for reducing it ('forward-looking responsibility'). Methods: We study how the two aspects of responsibility figure in the obesity policies of WHO (European Region), the EU and the Department of Health (England). Results: Responsibility for the emergence and reduction of obesity is assigned to both individuals and other actors to different degrees in the policies, combining an individual and a systemic view. The policies assign backward-looking responsibility to individuals, the social environment, the authorities and businesses. When it comes to forward-looking responsibility, individuals are expected to play a central role in reducing and preventing obesity, but other actors are also urged to act. WHO assigns to individuals the lowest degree of backward- and forward-looking responsibility, and the Department of Health (England) assigns them the highest degree of responsibility. Discussion: Differences in the assignment of backward- and above all forward-looking responsibility could be explained to some extent by the different roles of the three authorities making the plans. WHO is a UN agency with health as its goal, the EU is a liberal economic union with optimization of the internal European market as an important task, and England, as an independent sovereign country, has its own economic responsibilities. [ABSTRACT FROM AUTHOR]

Background The COVID-19 pandemic forced governments to implement lockdown policies to curb the spread of the disease. These policies explicitly encouraged homeworking, hence reducing the number of commuters with the implicit assumption that restricting peoples' movement reduces risk of infection for travellers and other people in their areas of residence and work. Yet, the spatial interrelation of different areas has been rarely addressed both in the public discourse and in early accounts of the various consequences of COVID-19. Methods Our study proposes a spatial analysis of the association between commuting flows and COVID-19 mortality in England between March and June 2020, using a range of publicly available area-level data. To account for spatial correlation, we used a structural mobility gravity model to analyze commuting flows between Local Authority Districts. By accounting for these spatial dependencies, we temper concerns of bias and inefficiency affecting simple linear estimates. Additionally, we disentangle the direct and indirect (from other areas) influence of commuting on COVID-19 mortality. Results The results of our spatial regression models suggest that higher commuting flows—in general and particularly by public transport—are associated with higher COVID-19 mortality. Our results are consistent with a reduction in COVID-related mortality after the introduction of a national lockdown in March. The spatial-lag term is statistically significant, highlighting the importance of accounting for spatial dependencies. Conclusion We suggest that considering spatial interactions through commuting or travel motivations may offer interesting perspectives on the trade-off between health and economic activity during lockdowns. [ABSTRACT FROM AUTHOR]

Background Employment histories influence health. However, most studies have so far investigated cross-sectional associations between employment histories and health, failing to recognize health as a dynamic process in later life. Methods We use Waves 3–8 of the English Longitudinal Study of Ageing, including retrospective information on respondents' employment activities. We used dynamic hamming distances to summarize lifetime employment histories up to state pension age (64 for men and 59 for women). Multilevel growth curve models were then used to estimate the influence of lifetime employment histories on later life health trajectories over a 10-year period using quality of life (QoL), somatic health, and depression. Results Net of selection effect and a host of contemporaneous material and social resources, men who exited early started off with poorer health than those with continuous attachment to the labour market but had a very similar health profile by the end of the 10-year period considered. Among women, better somatic health and higher QoL were observed among those who had employment breaks for family care, and this health advantage was maintained over time. Lifetime employment histories are not related to depression for either men or women. Conclusion Overall, differences in health by employment histories level off only among men who left earlier and those continuously employed. Flexible arrangements for men in poor health who benefit from leaving the labour market early and supporting women who wish to take breaks for family care may help reduce health inequalities in later life. [ABSTRACT FROM AUTHOR]

Background With the aim of decreasing immigration, the British government extended charging for healthcare in England for certain migrants in 2017. There is concern these policies amplify the barriers to healthcare already faced by asylum seekers and refugees (ASRs). Awareness has been shown to be fundamental to access. This article jointly explores (i) health care professionals' (HCPs) awareness of migrants' eligibility for healthcare, and (ii) ASRs' awareness of health services. Methods Mixed methods were used. Quantitative survey data explored HCPs' awareness of migrants' eligibility to healthcare after the extension of charging regulations. Qualitative data from semi-structured interviews with ASRs were analyzed thematically using Saurman's domains of awareness as a framework. Results In total 514 HCPs responded to the survey. Significant gaps in HCPs' awareness of definitions, entitlements and charging regulations were identified. 80% of HCP respondents were not confident defining the immigration categories upon which eligibility for care rests. Only a small minority (6%) reported both awareness and understanding of the charging regulations. In parallel, the 18 ASRs interviewed had poor awareness of their eligibility for free National Health Service care and suitability for particular services. This was compounded by language difficulties, social isolation, frequent asylum dispersal accommodation moves, and poverty. Conclusion This study identifies significant confusion amongst both HCP and ASR concerning eligibility and healthcare access. The consequent negative impact on health is concerning given the contemporary political climate, where eligibility for healthcare depends on immigration status. [ABSTRACT FROM AUTHOR]

Background To compare patterns of alcohol consumption and alcohol-related harm from a survey of university students sampled from universities in Denmark, England, Germany, Italy, Portugal and Switzerland. Methods A total of 2191 university students (70% female, 90% white ethnic group, age range 18–25) completed the survey. Participants completed measures of demographic variables (age, age of onset, ethnic group and sex) and the Alcohol Use Disorders Identification Test (AUDIT), which was the primary outcome. Results Sixty-three percent of the sample scored negative for harmful drinking on the AUDIT (<8), with 30% categorized as hazardous drinkers, 4% harmful drinkers and 3% with probable dependence. Analysis of variance, including demographic factors as covariates, identified a main effect of country on AUDIT scores F (5, 2086) = 70.97, P < 0.001, partial eta square = 0.15. AUDIT scores were highest in England (M = 9.99; SD = 6.17) and Denmark (M = 9.52; SD = 4.86) and lowest in Portugal (M = 4.90; ° = 4.60). Post hoc tests indicated large effect size differences between scores in Denmark and England and scores in all other countries (0.79 < d < 0.94; all P 's < 0.001). Conclusions European university students in our sample mainly reported low risk patterns of alcohol consumption and alcohol-related harm. However, students from Northern European countries had significantly higher AUDIT scores compared with students from Central and Southern European countries. Research is needed to replicate the present study using nationally representative samples to estimate the prevalence of alcohol use disorders among university students in different European countries. [ABSTRACT FROM AUTHOR]

Background Identifying ethnic inequalities in health requires data with sufficiently 'granular' (fine detailed) classifications of ethnicity to capture sub-group variation in healthcare use, risk factors and health behaviors. The Robert Wood Johnson Foundation (RWJF), in the USA, commissioned us to explore granular approaches to ethnicity data collection outside of the USA, commencing with the European Union. Methods We examined official data sources (population censuses/registers) within the EU-28 to determine the granularity of their approach to ethnicity. When ethnic information was not available, related variables were sought (e.g. country of birth). Results Within the EU-28, we found 55% of countries collected data on ethnicity. However, only 26% of these countries (England, Wales, Northern Ireland, Scotland, Republic of Ireland, Hungary, Poland and Slovakia) had a granular approach, with half of these being within the UK. Estonia, Lithuania, Croatia, Bulgaria, Republic of Cyprus and Slovenia collected one to six categories. A 'write-in' option only was found in Latvia, Romania and the Czech Republic. Forty-five percent of countries did not collect ethnicity data but collected other related variables. Conclusions (i) Although there is reasonable attention to the diversity of ethnic groups in data collection, a granular approach does not predominate within EU-28 classifications. (ii) Where ethnicity is collected, it is conceptualized in different ways and diverse terminology is used. (iii) A write-in option provides the most granular approach. (iv) Almost half of the countries did not collect data on ethnicity, but did collect related variables that could be used as a proxy. [ABSTRACT FROM AUTHOR]

Background Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF). Methods In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents' care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics. Results Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0–25.8) of residents in Poland to 77.9% (95% CI: 69.5–84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4–9.1) in Finland to 22.4% (95% CI: 14.7–32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6–12.8) in Finland to 47.9% (95% CI: 38.5–57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010). Conclusions Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases. [ABSTRACT FROM AUTHOR]

Background: The impact of flooding on mental health is exacerbated due to secondary stressors, although the mechanism of action is not understood. We investigated the role of secondary stressors on psychological outcomes through analysis of data collected one-year after flooding, and effect modification by sex. Methods: We analysed data from the English National Study on Flooding and Health collected from households flooded, disrupted and unexposed to flooding during 2013-14. Psychological outcomes were probable depression, anxiety and post-traumatic stress disorder (PTSD). Parsimonious multivariable logistic regression models were fitted to determine the effect of secondary stressors on the psychological outcomes. Sex was tested as an effect modifier using subgroup analyses. Results: A total of 2006 people participated (55.5% women, mean age 60 years old). Participants reporting concerns about their personal health and that of their family (concerns about health) had greater odds of probable depression (adjusted odds ratio [aOR] 1.77, 95% CI 1.17-2.65) and PTSD (aOR 2.58, 95% CI 1.82-3.66). Loss of items of sentimental value was associated with probable anxiety (aOR 1.82, 95% CI 1.26-2.62). For women, the strongest associations were between concerns about health and probable PTSD (aOR 2.86, 95% CI 1.79-4.57). For men, the strongest associations were between 'relationship problems' and probable depression (aOR 3.25, 95% CI 1.54-6.85). Conclusions: Concerns about health, problems with relationships and loss of sentimental items were consistently associated with poor psychological outcomes. Interventions to reduce the occurrence of these secondary stressors are needed to mitigate the impact of flooding on probable psychological morbidity. [ABSTRACT FROM AUTHOR]

Background: Research suggests that policymakers often use personal contacts to find information and advice. However, the main sources of information for public health policymakers are not known. This study aims to describe policymakers' sources of information. Methods: A questionnaire survey of public health policymakers across Greater Manchester (GM) was carried out (response rate 48%). All policy actors above Director level involved in public health policy (finding, analyzing or producing information, producing or implementing policy) in GM were included in the sampling frame. Respondents were provided with a list of sources of information and asked which they used (categorical data) and to name specific individuals who acted as sources of information (network data). Data were analyzed using frequencies and network analysis. Results: The most frequently chosen sources of information from the categorical data were NICE, government websites and Directors of Public Health. However, the network data showed that the main sources of information in the network were actually mid-level managers in the NHS, who had no direct expertise in public health. Academics and researchers did not feature in the network. Conclusions: Both survey and network analyses provide useful insights into how policymakers access information. Network analysis offers practical and theoretical contributions to the evidence-based policy debate. Identifying individuals who act as key users and producers of evidence allows academics to target actors likely to use and disseminate their work. [ABSTRACT FROM AUTHOR]

Background: Time spent in police custody should present an opportunity for the early identification of mental ill health. However, this stage of the criminal justice system (CJS) is currently the least developed in terms of its links with health and social services. In England, police custody sergeants administer a standardized risk assessment tool to determine a detainee's need for health-care and/or risk reduction measures while detained. Specialized mental health services are often reliant on this process to generate referrals; however, previous research has shown this to be ineffective. The aim of this study was to develop an improved mental health screening tool and referral pathway to better identify individuals with mental ill health in police custody. Methods: Mental health professionals, police officers and service users across six sites throughout England took part in qualitative interviews, controlled feedback consultations and an action learning group. Results: By combining a previously validated CJS mental health screening tool with elements of the custody risk assessment, the Police Mental Health Screening Questionnaire (PolQuest) was created. It is accompanied by a referral pathway that outlines services' responsibilities, expected actions and response times. Conclusion: The study resulted in a screening tool, referral pathway and training package. PolQuest is expected to facilitate the mental health screening of all adult detainees; improve the early identification of mental ill health; aid timely access to services; provide clear indicators for referral; and reduce ambiguity in the roles and responsibilities of staff across a range of criminal justice and health-care services. [ABSTRACT FROM AUTHOR]

Background: Although C-section is a highly effective procedure, literature abounds with evidence of overuse and particularly misuse, in lower-value indications such as low-risk deliveries. This study aims to quantify utilization of C-section in low-risk cases, mapping out areas showing excess-usage in each country and to estimate excess-expenditure as a proxy of the opportunity cost borne by healthcare systems. Methods: Observational, ecologic study on deliveries in 913 sub-national administrative areas of five European countries (Denmark, England, Portugal, Slovenia and Spain) from 2002 to 2009. The study includes a cross-section analysis with 2009 data and a time-trend analysis for the whole period. Main endpoints: age-standardized utilization rates of C-section in low-risk pregnancies and deliveries per 100 deliveries. Secondary endpoints: Estimated excess-cases per geographical unit of analysis in two scenarios of minimized utilization. Results: C-section is widely used in all examined countries (ranging from 19% of Slovenian deliveries to 33% of deliveries in Portugal). With the exception of Portugal, there are no systematic variations in intensity of use across areas in the same country. Cross-country comparison of lower-value C-section leaves Denmark with 10% and Portugal with 2%, the highest and lowest. Such behaviour was stable over the period of analysis. Within each country, the scattered geographical patterns of use intensity speak for local drivers playing a major role within the national trend. Conclusion: The analysis conducted suggests plenty of room for enhancing value in obstetric care and equity in women’s access to such within the countries studied. The analysis of geographical variations in lower-value care can constitute a powerful screening tool. [ABSTRACT FROM AUTHOR]

Introduction: Potentially avoidable hospitalizations in chronic conditions are used to evaluate health-care performance. However, evidence comparing different countries at small geographical areas is still scarce. The aim of the present study is to describe and discuss differences in rates and time-trends across health-care areas from five European countries. Methods: Observational, ecological study, on virtually all discharges produced in five European countries between 2002 and 2009. Potentially avoidable hospitalizations were operationally defined as a joint indicator composed of six chronic conditions. Episodes flagged as potentially avoidable were allocated to 913 geographical health-care areas. Age-sex standardized rates and standardized hospitalization ratios, as well as several statistics of variation, were estimated. Results: Four hundred sixty-two thousand seven hundred and ninety-two episodes were flagged as potentially avoidable. Variation in rates across countries was notable, from 93.7 cases per 10 000 inhabitants in Denmark to 34.8 cases per 10 000 inhabitants in Portugal. Within-country variation was also noteworthy, from 3.12 times among extreme areas in Spain to a 1.46-fold difference in Denmark. The highest systematic variation was found in Denmark (empirical Bayes 0.45) and the lowest in England (empirical Bayes 0.08). Rates and systematic variation remained fairly stable over time, with Denmark and England experiencing a statistically significant decrease (20% and 10%, respectively). Income and educational level, hospital utilization propensity, and region of residence were found to be associated with avoidable admissions. Conclusion: The dramatic variation across countries, beyond age and sex differences, and its consistency over time, implies systemic, although differential, behaviour of the five health-care systems with regard to chronic care. [ABSTRACT FROM AUTHOR]

Background: Circulatory disease mortality inequalities by country of birth (COB) have been demonstrated for some EU countries but pan-European analyses are lacking. We examine inequalities in circulatory mortality by geographical region/COB for six EU countries. Methods: We obtained national death and population data from Denmark, England and Wales, France, the Netherlands, Scotland and Sweden. Mortality rate ratios (MRRs) were constructed to examine differences in circulatory, ischaemic heart disease (IHD) and cerebrovascular disease mortality by geographical region/COB in 35–74 years old men and women. Results: South Asians in Denmark, England and Wales and France experienced excess circulatory disease mortality (MRRs 1.37–1.91). Similar results were seen for Eastern Europeans in these countries as well as in Sweden (MRRs 1.05–1.51), for those of Middle Eastern origin in Denmark (MRR = 1.49) and France (MRR = 1.15), and for East and West sub-Saharan Africans in England and Wales (MRRs 1.28 and 1.39) and France (MRRs 1.24 and 1.22). Low ratios were observed for East Asians in France, Scotland and Sweden (MRRs 0.64–0.50). Sex-specific analyses showed results of similar direction but different effect sizes. The pattern for IHD mortality was similar to that for circulatory disease mortality. Two- to three-fold excess cerebrovascular disease mortality was found for several foreign-born groups compared with the local-born populations in some countries. Conclusions: Circulatory disease mortality varies by geographical region/COB within six EU countries. Excess mortality was observed for some migrant populations, less for others. Reliable pan-European data are needed for monitoring and understanding mortality inequalities in Europe’s multiethnic populations. [ABSTRACT FROM PUBLISHER]

Background: Previous research has highlighted excess health morbidity in offender populations. A small number of studies have described health problems within police custody settings. The efficacy of police screening procedures has not been evaluated. Methods: Prospective clinical interviews with custody detainees in London were conducted. Clinical findings were compared with those recorded in police health screening documentation. Results: High levels of health morbidity were observed. The sensitivity and specificity of the current screen with respect to its ability to trigger a call for a health-care professional (HCP), regardless of the reason, was 70 and 66%, respectively. Fifty-one percent of the detainees with asthma, 36% with diabetes mellitus and 40% with epilepsy were not picked up by the screen. Fewer than one-half of the detainees at risk of alcohol withdrawal syndrome had ‘alcohol’ documented on their screen, although 81% saw the HCP. The police screen missed heroin use in 28% and crack cocaine use in 68% of users. A HCP was called in 84 and 64% of the cases, respectively, for any reason. Two of the 12 detainees (17%) who described a head injury with serious-associated symptoms were detected; 9 had a HCP called for any reason. Whereas mental disturbance was detected in 79% of the detainees with serious mental illness, one-third of the detainees with a risk history of suicide and one-half of the detainees with suicidal ideation were not documented as such on the police screen. Conclusion: Given the amounts of morbidity and the need for reliable triage, improvement in the health screening procedures used by the police is needed. [ABSTRACT FROM PUBLISHER]

Background: Inequalities in mortality are often presumed to exist at all ages. Here we examine whether this is true. Methods: We conducted an ecological study of mortality in England for 1997–99 using routinely collected public records. We used a (smoothed) single year of age rate of mortality for males and females by the multiple deprivation quintile of their ward of residence, for all and specific causes to assess if inequalities varied by age. Results: For most ages, a greater mortality risk exists for those living in the most deprived compared with the least deprived quintile of wards. However, during late adolescence there is equality. The equalization occurs at the age of 17–19 years. There is a longer period of 10 years for females and 20 years for males of convergence and then divergence centred on late adolescence and young adulthood. The equalization is driven principally through a heightened exposure to the risk of land transport accidents and a resulting higher than expected rate of mortality for the least deprived rather than a decrease in risk for the most deprived. Conclusions: It seems likely that an increase in risk taking associated with late adolescence combined with exposure to a relatively dangerous transport environment leads to large increases in risk for young people in the least deprived parts of England. As a result mortality inequality disappears at this age. [ABSTRACT FROM PUBLISHER]

Background: Studies using English administrative data from the Hospital Episode Statistics (HES) are increasingly used for the assessment of health-care quality. This study aims to catalogue the published body of studies using HES data to assess health-care outcomes, to assess their methodological qualities and to determine if reporting recommendations can be formulated. Methods: Systematic searches of the EMBASE, Medline and Cochrane databases were performed using defined search terms. Included studies were those that described the use of HES data extracts to assess health-care outcomes. Results: A total of 148 studies were included. The majority of published studies were on surgical specialties (60.8%), and the most common analytic theme was of inequalities and variations in treatment or outcome (27%). The volume of published studies has increased with time (r = 0.82, P < 0.0001), as has the length of study period (r = 0.76, P < 0.001) and the number of outcomes assessed per study (r = 0.72, P = 0.0023). Age (80%) and gender (57.4%) were the most commonly used factors in risk adjustment, and regression modelling was used most commonly (65.2%) to adjust for confounders. Generic methodologic data were better reported than those specific to HES data extraction. For the majority of parameters, there were no improvements with time. Conclusions: Studies published using HES data to report health-care outcomes have increased in volume, scope and complexity with time. However, persisting deficiencies related to both generic and context-specific reporting have been identified. Recommendations have been made to improve these aspects as it is likely that the role of these studies in assessing health care, benchmarking practice and planning service delivery will continue to increase. [ABSTRACT FROM AUTHOR]

Background: Little is known about the differential impact of comprehensive and partial smoke-free legislation on smoking cessation. This study aimed to examine the impact of comprehensive smoke-free workplace legislation in Ireland and England, and partial hospitality industry legislation in the Netherlands on quit attempts and quit success. Methods: Nationally representative samples of 2,219 adult smokers were interviewed in three countries as part of the International Tobacco Control (ITC) Europe Surveys. Quit attempts and quit success were compared between period 1 (in which smoke-free legislation was implemented in Ireland and the Netherlands) and period 2 (in which smoke-free legislation was implemented in England). Results: In Ireland, significantly more smokers attempted to quit smoking in period 1 (50.5%) than in period 2 (36.4%) (p < 0.001). Percentages of quit attempts and quit success did not change significantly between periods in the Netherlands. English smokers were significantly more often successful in their quit attempt in period 2 (47.3%) than in period 1 (26.4%) (p = 0.011). In the first period there were more quit attempts in Ireland than in England and fewer in the Netherlands than in Ireland. Fewer smokers quitted successfully in the second period in both Ireland and the Netherlands than in England. Conclusion: The comprehensive smoke-free legislation in Ireland and England may have had positive effects on quit attempts and quit success respectively. The partial smoke-free legislation in the Netherlands probably had no effect on quit attempts or quit success. Therefore, it is recommended that countries implement comprehensive smoke-free legislation. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the association of rising type 2 diabetes prevalence with socio-economic inequality in diabetes. Methods: Data from the Health Survey for England were analysed for 1994, 1998, 2003 and 2006. This is a nationally representative annual survey of private households. Data for 41 643 individuals aged &geq;35 years were included. The prevalence of self-reported diabetes diagnosed by a doctor was analysed in relation to household income, occupational social class and educational qualifications. Data were standardized for age using the European Standard Population for reference. Results: Prevalence of diagnosed diabetes increased in men from 3.74% in 1994 to 7.25% in 2006, and in women from 2.28% to 4.88%. In 1994, there were no associations between social class or educational level and diabetes prevalence evident. In 2006, there was evidence of a negative association in women [prevalence ratio for social class (IV + V vs. I) = 4.54, P-value for trend = 0.005; prevalence ratio for educational level (‘none’ vs. ‘A-levels’) = 1.96, P-value for trend = 0.001]. The Slope Index of Inequality (SII) for social class in women increased from –1.65 in 1994 to –4.95 [95% Confidence Interval (95% CI –8.52 to –1.38)] in 2006 and for level of education from –1.39 to –6.48 (95% CI –9.03 to –3.93). In men, diabetes prevalence was not associated with social class or level of education. Conclusion: Increasing prevalence of type 2 diabetes has been associated with an increase of socio-economic inequality in women. There was no socio-economic gradient observed in men. [ABSTRACT FROM PUBLISHER]

Background: In England, although some studies report better health among rural populations, few have examined social inequalities in health within rural areas and how they compare to inequalities observed in urban settings. The objectives of this study are to examine (i) whether living in rural, in more affluent and in more socially cohesive areas is associated with better mental health; and (ii) whether being in employment is more protective for mental health in rural than in urban areas. Methods: Data on common mental disorders (CMD) and socio-demographic characteristics of 12 962 adults are from the Health Survey for England. Individuals resided in 892 areas categorized as urban or rural. Area deprivation is measured using the employment deprivation domain from the 2004 Index of Multiple Deprivation. Area social cohesion is derived from individuals’ perceptions using ecometric procedures. Data are analysed using multilevel logistic models. Results: Living in rural areas is significantly associated with lower risk of reporting CMD [odds ratio (OR): 0.81; 95% confidence interval (CI): 0.71–0.92], independently of individuals’ characteristics, and of area deprivation and social cohesion. The mental health advantage of being in employment is more important in rural areas (OR: 0.74; 95% CI: 0.58–0.95) than in urban settings. Conclusion: Living in rural areas is associated with better overall mental health. Yet inequalities in mental health between people in the workforce and those who are not are more important in rural settings. More studies are needed to understand the patterning of social inequalities in health in rural communities. [ABSTRACT FROM AUTHOR]

Background: Adolescent smoking is a significant public health concern in the UK and across Europe. This study examines smoking behaviours, methods of accessing cigarettes and use of non-commercial (fake, foreign and single) cigarettes across a sample of schoolchildren. Relationships with alcohol consumption, deprivation, personal income and extra-curricular activities are also explored. Methods: A cross-sectional survey of 9833 15- and 16-year-old schoolchildren in the North West of England. Results: Cigarettes were most commonly accessed from off-licences and newsagents, but pupils also reported non-commercial access through friends, family and street sellers/neighbours. A high percentage of smokers had bought foreign (57%), fake (28%) and single (54%) cigarettes. Frequent binge drinking, not participating in extra-curricular activities, receiving greater personal income, and having parents that smoked were significantly associated with being a regular and heavier smoker. Frequent binge drinking was also significantly associated with buying foreign/fake or single cigarettes. A higher percentage of those living in deprived areas were current smokers, although deprivation was not an independent predictor of cigarette use. Conclusion: Strategies that restrict commercial access to cigarettes among adolescents may increase their reliance on social methods of access, and use of fake, foreign and single cigarettes. Interventions to reduce adolescent smoking must recognize the critical role of parents and communities in discouraging smoking and preventing social access to cigarettes in children. A joint approach to prevention is required that targets children at risk of smoking, heavy alcohol use and associated health-damaging behaviours. [ABSTRACT FROM AUTHOR]

Background: Tobacco companies target young adults through marketing strategies that use bars and nightclubs to promote smoking. As restrictions increasingly limit promotions, music marketing has become an important vehicle for tobacco companies to shape brand image, generate brand recognition and promote tobacco. Methods: Analysis of previously secret tobacco industry documents from British American Tobacco, available at http://legacy.library.ucsf.edu. Results: In 1995, British American Tobacco (BAT) initiated a partnership with London’s Ministry of Sound (MOS) nightclub to promote Lucky Strike cigarettes to establish relevance and credibility among young adults in the UK. In 1997, BAT extended their MOS partnership to China and Taiwan to promote State Express 555. BAT sought to transfer values associated with the MOS lifestyle brand to its cigarettes. The BAT/MOS partnership illustrates the broad appeal of international brands across different regions of the world. Conclusion: Transnational tobacco companies like BAT are not only striving to stay contemporary with young adults through culturally relevant activities such as those provided by MOS but they are also looking to export their strategies to regions across the world. Partnerships like this BAT/MOS one skirt marketing restrictions recommended by the World Health Organization’s Framework Convention on Tobacco Control. The global scope and success of the MOS program emphasizes the challenge for national regulations to restrict such promotions. [ABSTRACT FROM AUTHOR]

Background: The internet has become a key tool in health research and is increasingly used for data collection via email and web-surveys. Whilst the demographics of those with and without access to the Internet in the UK are regularly reported, the health behaviours of those who choose to take part in web-based surveys, compared to the wider population, are not known. Methods: We compared the health behaviours of those responding to a web-based health and lifestyle survey advertised on regional TV and radio news with regional results from a large national health and lifestyle survey—the Health Survey for England 2003. Results: After exclusion of duplicates, 1116 individuals responded to the survey and provided information on age and sex as well as a postcode in the Government Office for the North East region. Those responding to the web-survey were younger and lived in less deprived areas than the regional population. After weighting survey responses for age and deprivation, respondents to the survey reported higher mean BMI, greater fruit and vegetable consumption, as well as differing patterns of physical activity, alcohol consumption and smoking, than regional respondents to the Health Survey for England. Conclusions: Conducting a web-based health and lifestyle survey advertised on regional news media was fast, cheap and relatively easy. Given the potential benefits of web-based surveys, further work is justified exploring who responds to web-based health and lifestyle surveys and whether or not more representative samples can be obtained. [ABSTRACT FROM AUTHOR]

Objective: To identify the links between smuggled tobacco, deprivation and addiction across one Health Authority in the North East of England and identify the impact on people living in disadvantaged areas. Design: Anonymous postal survey. Sample size 11 443. Multivariate analysis including an 'Ideal Types analysis' examined the probabilities of purchase of smuggled tobacco and associations with population characteristics. Setting: Sample taken from across the Hull & East Riding Health Authority area in the UK. Participants: Randomly selected from those aged 16 and over, who were registered with a GP in the Health Authority area on the 1 September 2000. Results: The predicted probability of having ever bought smuggled tobacco for a male, employed, heavy smoker living in a deprived area was 0.67. A female with the same characteristics had a probability of 0.49. For the unemployed the probabilities are 0.55 and 0.37 respectively. For respondents living in non-deprived areas the probability of having ever bought smuggled tobacco was much lower. This probability was further reduced for respondents who were unemployed. Respondents living in deprived areas had a 134% higher probability of being heavily addicted to tobacco. Links between addiction and deprivation are confirmed. Conclusions: This study confirms and extends the findings of previous qualitative studies. The results of this analysis demonstrate that people who have bought smuggled tobacco are heavy smokers with high levels of addiction, living in socially deprived areas, but are more likely to be in employment. They are likely to use smuggled tobacco to save money and sustain their smoking habit. [ABSTRACT FROM AUTHOR]

Presents a study which assessed smoking cessation among representatives of typical smokers in England to see the effectivity of cessation aids. Descriptive information showing the patterns of use of nicotine replacement therapies and other cessation aids; Relation of contact with health professionals to a successful cessation; Impact of the knowledge of the health consequences of smoking on the smoking status of individuals.

Presents a study that examines the experience of converting the Master of Public Health degrees at the University of Liverpool in Liverpool, England into one that combines both distance learning and contact time in the classrooms. Methodology used in the study; Discussion on the results of the study; Explanation on the conclusion of the study.

The article discusses the Health Action Zone (HAZ) in England. HAZ focuses on community-based activities aimed to tackle health inequalities both nationally and internationally. Among the strategic objectives of HAZ include the addressing of public health needs, increase in the efficiency of medical services and the development of partnerships for improving public health.

Presents a study that investigated the extent to which students in the North East of England are exposed to two alternative tobacco marketing tactics. Information on direct mailing and corporate sponsorship marketing tactics of tobacco manufacturers; Methodology used in the study; Discussion on the data used in the study; Examination on the results of the study; Conclusion.

Presents a study that examined the prevalence of drug misusers in Cheshire, England. Analysis of misuse of opiates, amphetamines or cocaine; Incidence of AIDS among injecting drug misusers; Results of the study.