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Rationale, aims and objective: Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting. Method: The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible. Results: A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers. Conclusions: Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design. [ABSTRACT FROM AUTHOR]

Introduction: Non-medical prescribing has the potential to deliver innovative healthcare within limited finances. However, uptake has been slow, and a proportion of non-medical prescribers do not use the qualification. This systematic review aimed to describe the facilitators and barriers to non-medical prescribing in the United Kingdom. Methods: The systematic review and thematic analysis included qualitative and mixed methods papers reporting facilitators and barriers to independent non-medical prescribing in the United Kingdom. The following databases were searched to identify relevant papers: AMED, ASSIA, BNI, CINAHL, EMBASE, ERIC, MEDLINE, Open Grey, Open access theses and dissertations, and Web of Science. Papers published between 2006 and March 2017 were included. Studies were quality assessed using a validated tool (QATSDD), then underwent thematic analysis. The protocol was registered with PROSPERO (CRD42015019786). Results: Of 3991 potentially relevant identified studies, 42 were eligible for inclusion. The studies were generally of moderate quality (83%), and most (71%) were published 2007–2012. The nursing profession dominated the studies (30/42). Thematic analysis identified three overarching themes: non-medical prescriber, human factors, and organisational aspects. Each theme consisted of several sub-themes; the four most highly mentioned were ‘medical professionals’, ‘area of competence’, ‘impact on time’ and ‘service’. Sub-themes were frequently interdependent on each other, having the potential to act as a barrier or facilitator depending on circumstances. Discussion: Addressing the identified themes and subthemes enables strategies to be developed to support and optimise non-medical prescribing. Further research is required to identify if similar themes are encountered by other non-medical prescribing groups than nurses and pharmacists. [ABSTRACT FROM AUTHOR]

Physical inactivity has been identified as a leading risk factor for premature mortality globally, and adolescents, in particular, have low physical activity levels. Schools have been identified as a setting to tackle physical inactivity. Economic evidence of school-based physical activity programmes is limited, and the costs of these programmes are not always collected in full. This paper describes a micro-costing and cost-consequence analysis of the ‘Girls Active’ secondary school-based programme as part of a cluster randomised controlled trial (RCT). Micro-costing and cost-consequence analyses were conducted using bespoke cost diaries and questionnaires to collect programme delivery information. Outcomes for the cost-consequence analysis included health-related quality of life measured by the Child Health Utility-9D (CHU-9D), primary care General Practitioner (GP) and school-based (school nurse and school counsellor) service use as part of a cluster RCT of the ‘Girls Active’ programme. Overall, 1,752 secondary pupils were recruited and a complete case sample of 997 participants (Intervention n = 570, Control n = 427) was used for the cost-consequence analysis. The micro-costing analysis demonstrated that, depending upon how the programme was delivered, ‘Girls Active’ costs ranged from £1,054 (£2 per pupil, per school year) to £3,489 (£7 per pupil, per school year). The least costly option was to absorb ‘Girls Active’ strictly within curriculum hours. The analysis demonstrated no effect for the programme for the three main outcomes of interest (health-related quality of life, physical activity and service use).Micro-costing analyses demonstrated the costs of delivering the ‘Girls Active’ programme, addressing a gap in the United Kingdom (UK) literature regarding economic evidence from school-based physical activity programmes. This paper provides recommendations for those gathering cost and service use data in school settings to supplement validated and objective measures, furthering economic research in this field. Trial registration: -ISRCTN, . [ABSTRACT FROM AUTHOR]

Introduction: Non-medical prescribing was introduced into the United Kingdom (UK) to improve patient care, through extending healthcare professionals’ roles. More recent government health service policy focuses on the increased demand and the need for efficiency. This systematic policy review aimed to describe any changes in government policy position and the role that non-medical prescribing plays in healthcare provision. Method: The systematic policy review included policy and consultation documents that describe independent non-medical prescribing. A pre-defined protocol was registered with PROSPERO (CRD42015019786). Professional body websites, other relevant websites and the following databases were searched to identify relevant documents: HMIC, Lexis Nexis, UK Government Web Archive, UKOP, UK Parliamentary Papers and Web of Science. Documents published between 2006 and February 2018 were included. Results and discussion: Following exclusions, 45 documents were selected for review; 23 relating to policy or strategy and 22 to consultations. Of the former, 13/23 were published 2006–2010 and the remainder since 2013. Two main themes were identified: chronological aspects and healthcare provision. In the former, a publication gap for policy documents resulted from a change in government and associated major healthcare service reorganisation. In the later, the role of non-medical prescribing was found to have evolved to support efficient service delivery, and cost reduction. For many professions, prescribing appears embedded into practice; however, the pharmacy profession continues to produce policy documents, suggesting that prescribing is not yet perceived as normal practice. Conclusion: Prescribing appears to be more easily adopted into practice where it can form part of the overall care of the patient. Where new roles are required to be established, then prescribing takes longer to be universally adopted. While this review concerns policy and practice in the UK, the aspect of role adoption has wider potential implications. [ABSTRACT FROM AUTHOR]

Background: Centile curves and standard scores are common in epidemiological research. However, standardised norms and centile growth curves for language disorder that reflect the entire UK local school population do not exist. Methods: Scores on six language indices assessing receptive and expressive functioning of children were obtained from the SCALES population survey. Monolingual English speaking participants were aged between five and nine years. Children who attended special schools at study intake, or who were learning English as an additional language were excluded. We constructed language norms using the LMS method of standardisation which allows for skewed measurements. We made use of probability weights that were produced from a two-step logistic model. Distributions of estimated standard scores from an intensively assessed sub-population and from the full population were contrasted to demonstrate the role of weights. Results: Non-overlapping centile curves and standardised scores at each age were obtained for the six language indices. The use of weights was essential at retrieving the target distribution of the scores. An online calculator that estimates standardised scores for the measures was constructed and made freely available. Conclusions: The findings highlight the usefulness and flexibility of the LMS method at dealing with the standardisation of linguistic and educational measures that are sufficiently continuous. The paper adds to the existing literature by providing population norms for a number of language tests that were calculated from the same group of individuals. [ABSTRACT FROM AUTHOR]

Castanea sativa is classified as non-indigenous in Britain and Ireland. It was long held that it was first introduced into Britain by the Romans, until a recent study found no corroborative evidence of its growing here before c. AD 650. This paper presents new data on the genetic diversity of C. sativa in Britain and Ireland and potential ancestral sources in continental Europe. Microsatellite markers and analytical methods tested in previous European studies were used to genotype over 600 C. sativa trees and coppice stools, sampled from ancient semi-natural woodlands, secondary woodlands and historic cultural sites across Britain and Ireland. A single overall genepool with a diverse admixture of genotypes was found, containing two sub groups differentiating Wales from Ireland, with discrete geographical and typological clusters. C. sativa genotypes in Britain and Ireland were found to relate predominantly to some sites in Portugal, Spain, France, Italy and Romania, but not to Greece, Turkey or eastern parts of Europe. C. sativa has come to Britain and Ireland from these western European areas, which had acted as refugia in the Last Glacial Maximum; we compare its introduction with the colonization/translocation of oak, ash, beech and hazel into Britain and Ireland. Clones of C. sativa were identified in Britain, defining for the first time the antiquity of some ancient trees and coppice stools, evincing both natural regeneration and anthropogenic propagation over many centuries and informing the chronology of the species’ arrival in Britain. This new evidence on the origins and antiquity of British and Irish C. sativa trees enhances their conservation and economic significance, important in the context of increasing threats from environmental change, pests and pathogens. [ABSTRACT FROM AUTHOR]

The European Emission Trading System (EU ETS) is commonly regarded as the key pillar of the European climate policy and as the main unifying tool to create a unique carbon price all over Europe. The UK has always played a crucial role in the EU ETS, being one of the most active national registry and a crucial hub for the exchange of allowances in the market. Brexit, therefore, could deeply modify the number and directions of such exchanges as well as the centrality of the other countries in this system. To investigate these issues, the present paper exploits network analysis tools to compare the structure of the EU ETS market in its first two phases with and without the UK, investigating a few different scenarios that might emerge from a possible reallocation of the transactions that have involved UK partners. We find that without the UK the EU ETS network would become in general much more homogeneous, though results may change focusing on the type of accounts involved in the transactions. [ABSTRACT FROM AUTHOR]

Background: Childhood obesity is a serious public health challenge and schools have been identified as an ideal place to implement prevention interventions. The aim of this study was to measure the cost-effectiveness of a multi-faceted school-based obesity prevention intervention targeting children aged 6–7 years when compared to ‘usual activities’. Methods: A cluster randomised controlled trial in 54 schools across the West Midlands (UK) was conducted. The 12-month intervention aimed to increase physical activity by 30 minutes per day and encourage healthy eating. Costs were captured from a public sector perspective and utility-based health related outcomes measured using the CHU-9D. Multiple imputation using chained equations was used to address missing data. The cost effectiveness was measured at 30 months from baseline using a hierarchical net-benefit regression framework, that controlled for clustering and prespecified covariates. Any uncertainty in the results was characterised using cost-effectiveness acceptability curves. Results: At 30 months, the total adjusted incremental mean cost of the intervention was £155 (95% confidence interval [CI]: £139, £171), and the incremental mean QALYs gained was 0.006 (95% CI: -0.024, 0.036), per child. The incremental cost-effectiveness at 30 months was £26,815 per QALY and using a standard willingness to pay threshold of £30,000 per QALY, there was a 52% chance that the intervention was cost-effective. Conclusions: The cost-effectiveness of the school-based WAVES intervention was subject to substantial uncertainty. We therefore recommend more research to explore obesity prevention within schools as part of a wider systems approach to obesity prevention. Trial registration: This paper uses data collected by the WAVES trial: Controlled trials (registered May 2010). [ABSTRACT FROM AUTHOR]

Background: Patient and public involvement (PPI) is a requirement for UK health and social care research funding. Evidence for how best to implement PPI in research programmes, such as National Institute for Health Research (NIHR) Collaborations for Applied Health Research and Care (CLAHRCs), remains limited. This paper reports findings from an action research (AR) project called IMPRESS, which aims to strengthen PPI within CLAHRC East of England (EoE). IMPRESS combines AR with Normalisation Process Theory (NPT) to explore PPI within diverse case study projects, identifying actions to implement, test and refine to further embed PPI. Methods: We purposively selected CLAHRC EoE case study projects for in-depth analysis of PPI using NPT. Data were generated from project PPI documentation, semi-structured qualitative interviews with researchers and PPI contributors and focus groups. Transcripts and documents were subjected to abductive thematic analysis and triangulation within case. Systematic across case comparison of themes was undertaken with findings and implications refined through stakeholder consultation. Results: We interviewed 24 researchers and 13 PPI contributors and analysed 28 documents from 10 case studies. Three focus groups were held: two with researchers (n = 4 and n = 6) and one with PPI contributors (n = 5). Findings detail to what extent projects made sense of PPI, bought in to PPI, operationalised PPI and appraised it, thus identifying barriers and enablers to fully embedded PPI. Conclusion: Combining NPT with AR allows us to assess the embeddedness of PPI within projects and programme, to inform specific local action and report broader conceptual lessons for PPI knowledge and practice informing the development of an action framework for embedding PPI in research programmes. To embed PPI within similar programmes teams, professionals, disciplines and institutions should be recognised as variably networked into existing PPI support. Further focus and research is needed on sharing PPI learning and supporting innovation in PPI. [ABSTRACT FROM AUTHOR]

Background: The accessibility of services within community pharmacies provides an ideal opportunity to manage minor ailments, yet over £1.1 billion is spent by the National Health Service (NHS) in the United Kingdom (UK) in managing minor ailments in high cost settings. There is a need to review the evidence base around clinical effectiveness of pharmacy-based management of minor ailments since the absence of such may lead to under-utilisation of pharmacy services and non-implementation of available pharmacy service models. This study aimed to systematically review the methodological approaches used to assess clinical outcomes of pharmacy-based management of minor ailments in the research literature. Methods: A systematic review was conducted to identify relevant literature using the following databases: Medline, EMBASE, CINAHL, IPA, CRD, CDSR, and Google Scholar from publication year 2000 onwards. Studies were included if they evaluated clinical outcomes of pharmacy-based management of any minor ailments, with or without a comparator setting such as Emergency Departments (EDs) or general practices. Screening and selection of titles, abstracts and full texts followed by data extraction and quality assessment (QA) was conducted. Paired researchers, from the team, reviewed papers using a protocol based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). QA was undertaken using the Critical Appraisal Skills Programme (CASP). Reporting was conducted in accordance with PRISMA checklist and statements. Results: A total of 19 studies were included. The majority of studies were observational, conducted in community pharmacies, and did not use a comparator participant group nor a comparator setting. Interventions included counselling, medicines supply and provision of advice on the management of minor ailments. One study used the randomised controlled trial (RCT) design with majority of the study utilising observational design. A range of clinical outcomes including symptom severity, pattern, resolution, and quality of life were reported. Methods used for the assessment of clinical outcomes were, overall, poorly reported. This included a lack of information on the development and validation of the data collection tools and the timing of baseline and follow-up data collection. Adverse clinical outcomes data were collected by only seven studies. Conclusions: Currently, there are methodological limitations in the studies that have sought to assess clinical outcomes of pharmacy-based management of minor ailments. Such lack of high quality evidence may contribute to failings to shift care from high cost settings, such as EDs and general practices. Generation of high quality evidence is likely to influence public choices when seeking care for minor ailments. There is scope for development of a core outcomes set specific to minor ailments management and development of a validated methodology for measuring such outcomes in a research study. [ABSTRACT FROM AUTHOR]

Background: Speech and language therapy provision for aphasia (a language disorder) post stroke has been studied over time through surveys completed by speech and language therapists. This paper revisits provision based on what was received by 278 patients in 21 UK speech and language therapy departments in 2014–2016. Aims: To explore the speech and language therapy received by community dwelling people with post stroke aphasia in the UK. Methods and procedures: A quantitative content analysis was conducted by two speech and language therapist researchers. Therapy goals recorded were coded into categories and subcategories. Descriptive statistics were used to identify the frequency with which goal categories were targeted, average therapy time received, length and frequency of therapy sessions, personnel involved and mode of delivery. Outcomes and results: Forty-five percent of participants were in receipt of therapy in the three month window observed. Six goal categories were identified. Rehabilitation was the most frequent (60%) followed by enabling (17.2%), review (4.3%), assessment (3.6%), supportive (3.5%) and activity to support therapy (2.8%). The median amount of therapy received in three months was 6.3 hours at an average of one 60-minute session every two weeks. Seventy-seven percent of therapy sessions were delivered by qualified speech and language therapists and 23% by assistants. Ninety percent of sessions were one to one, face to face sessions whilst 9.5% were group sessions. Discussion: In line with previous reports, speech and language therapy for community dwelling stroke survivors with aphasia is restricted. Rehabilitation is a large focus of therapy but the intensity and dose with which it is provided is substantially lower than that required for an effective outcome. Despite this, one to one face to face therapy is favoured. More efficient methods to support more therapeutic doses of therapy are not commonly used in routine clinical services. [ABSTRACT FROM AUTHOR]

Personhood discourses in dementia care have gained prominence and current care home standards mandate that care should be “person-centred”. However, it is unclear how the personhood of staff is construed within the care relationship. This paper aims to explore how the personhood of paid carers of people with dementia can be understood by focussing on the views and experiences of care home staff. We undertook a secondary qualitative analysis of interviews with 25 paid care staff in England, conducted as part of the MARQUE (Managing Agitation and Raising QUality of lifE) study. The authors inductively developed themes around the topic of personhood for staff, contrasting management and care staff perspectives. We found that many care staff are not identified as persons in their own right by their employing institutions, and that there is a general lack of acknowledgment of the moral work of caring that occurs within formal care work. This oversight can reduce the complex relationships of care work to a series of care tasks, challenges care workers’ self-worth and self-efficacy, and impede their efforts to deliver person-centred care. We conclude that care staff status as persons in their own right should be explicitly considered in quality standards and supported by employers’ policies and practices, not simply for their role in preserving the personhood of people with dementia but for their own sense of valued personhood. Enhancing staff personhood may also result in improved care. [ABSTRACT FROM AUTHOR]

Purpose: There is a general inquisition regarding the monetary value of a research output, as a substantial amount of funding in modern academia is essentially awarded to good research presented in the form of journal articles, conferences papers, performances, compositions, exhibitions, books and book chapters etc., which, eventually leads to another question if the value varies across different disciplines. Answers to these questions will not only assist academics and researchers, but will also help higher education institutions (HEIs) make informed decisions in their administrative and research policies. Design and methodology: To examine both the questions, we applied the United Kingdom’s recently concluded national research assessment exercise known as the Research Excellence Framework (REF) 2014 as a case study. All the data for this study is sourced from the openly available publications which arose from the digital repositories of REF’s results and HEFCE’s funding allocations. Findings: A world leading output earns between £7504 and £14,639 per year within the REF cycle, whereas an internationally excellent output earns between £1876 and £3659, varying according to their area of research. Secondly, an investigation into the impact rating of 25315 journal articles submitted in five areas of research by UK HEIs and their awarded funding revealed a linear relationship between the percentage of quartile-one journal publications and percentage of 4* outputs in Clinical Medicine, Physics and Psychology/Psychiatry/Neuroscience UoAs, and no relationship was found in the Classics and Anthropology/Development Studies UoAs, due to the fact that most publications in the latter two disciplines are not journal articles. Practical implications: The findings provide an indication of the monetary value of a research output, from the perspectives of government funding for research, and also what makes a good output, i.e. whether a relationship exists between good quality output and the source of its publication. The findings may also influence future REF submission strategies in HEIs and ascertain that the impact rating of the journals is not necessarily a reflection of the quality of research in every discipline, and this may have a significant influence on the future of scholarly communications in general. Originality: According to the author’s knowledge, this is the first time an investigation has estimated the monetary value of a good research output. [ABSTRACT FROM AUTHOR]

Background: From April 6th 2015, all small shops in the UK were required to cover up tobacco products at point of sale (POS) to protect children from exposure. As part of a larger 5-year study to measure the impact of the legislation in Scotland, an audit was conducted to assess level and nature of compliance with the ban immediately following its introduction. Materials and Methods: A discreet observational audit was conducted 7–14 days post implementation which took measures of physical changes made to cover products, server/assistant practices, tobacco signage and advertising, and communication of price information. The audit was conducted in all small retail outlets (n = 83) selling tobacco in four communities in Scotland selected to represent different levels of urbanisation and social deprivation. Data were analysed descriptively. Results: Compliance with the legislation was high, with 98% of shops removing tobacco from permanent display and non-compliance was restricted almost entirely to minor contraventions. The refurbishment of shops with new or adapted tobacco storage units resulted in the removal of nearly all commercial brand messages and images from POS, dropping from 51% to 4%. The majority of shops stored their tobacco in public-facing storage units (81%). Most shops also displayed at least one generic tobacco message (88%). Conclusions: Compliance with Scottish prohibitions on display of tobacco products in small retail outlets was high immediately after the legislation implementation date. However, although tobacco branding is no longer visible in retail outlets, tobacco storage units with generic tobacco messages are still prominent. This points towards a need to monitor how the space vacated by tobacco products is utilised and to better understand how the continuing presence of tobacco storage units influences people’s awareness and understanding of tobacco and smoking. Countries with existing POS bans and who are considering such bans should pay particular attention to regulations regarding the use of generic signage and where within the retail setting tobacco stocks can be stored. [ABSTRACT FROM AUTHOR]

Objective: To explore, through face to face interviews with a selection of General Dental Practitioners (GDPs), their views and experiences of having used the International Caries Detection and Assessment System (ICDAS) within primary care research studies for recording caries. Methods: This qualitative study involved one on one interviews with eight GDP’s who had previously used ICDAS on patients in their dental practices as part of a research study. The participants were selected from among those who had taken part in two clinical studies in the UK using convenient, but purposive sampling. The interviews were tape-recorded and transcribed; the data analysis was conducted by thematic analysis. Results: GDP’s indicated their beliefs that ICDAS had an important role in caries prevention but reported four main barriers while using the full (6 caries stages) ICDAS coding system in their practices: lack of simplicity of coding, financial implications and time consumption (in both training and use of ICDAS) and inadequate undergraduate training. An overarching theme identified from the GDPS was the willingness to offer potential solutions to their barriers which might improve the utilisation of the system in primary care. Conclusion: The GDPs experienced common obstacles in using ICDAS in the primary care setting, many of which have relatively straight-forward solutions which they put forward themselves such as: incentivisation, undergraduate-level training in ICDAS for both dentists and nurses and computerized data entry. Further qualitative and quantitative research is needed on how to facilitate the utilisation of the system in dental practice. It is also recommended to explore the influences of wider agencies on influencing primary dental care professionals’ caries management, including appropriate recording of diagnosis and risk assessment. [ABSTRACT FROM AUTHOR]

Background: Encephalitis, characterised as inflammation of the brain tissue, is an important cause of acquired brain injury in children. Objective clinical outcomes vary significantly between affected patients, however they do not always correlate with quality of life as reported by parents. The aim of this study was to explore how parents experience and interpret outcomes in relation to their child who has been affected by encephalitis. Methods: Data were derived from in-depth, semi-structured interviews, with 15 parents of 12 children and young people affected by encephalitis. Paediatric cases were identified from the retrospective arm of the research programme ‘ENCEPH-UK-Understanding and Improving the Outcome of Encephalitis’, and from the prospective UK childhood meningitis and encephalitis cohort study (UK-ChiMES, 2012 to 2016). Data were analysed thematically. Results: Parents’ perspectives on important outcomes for their child and family changed during the different stages of the encephalitis illness trajectory: from acute illness, recovery and rehabilitation, then reintegration into everyday life. Parents’ understanding of their children’s overall outcome was informed by their own experiences, involving comparisons with other children and reflections on their child’s problems before, during and after the acute illness. Conclusion: Outcomes in paediatric encephalitis need to be understood in terms of the context of the patient and family experience as well as the timeframe of recovery. The research highlights the need to include more patient, parent and/or carer reported outcome measures during patient assessment, and that assessment should be repeated during recovery as family concerns change. In the longer term, these parameters could be included in clinical and rehabilitation practice to further support child recovery. [ABSTRACT FROM AUTHOR]

Bemisia tabaci (the tobacco whitefly) is an important agricultural pest of global significance primarily because of its ability to transmit multiple damaging plant viruses. To date, UK outbreaks of the whitefly have been restricted to glasshouses and there are no records of the whitefly establishing outdoors during the summer. This is despite the fact that annual degree-day models (that estimate accumulated warmth over the year above the development threshold), indicate that B. tabaci has the thermal potential for multiple summer generations in the UK. A set of 49 climate indices calculated using the present day climate (1986–2015) were therefore compared between the UK and the south of France, where B. tabaci is able to establish outdoors, to identify the factors limiting its establishment. The number of cold days and nights in summer, as well as the time spent within the whitefly’s optimum temperature range, were most significantly different between the two areas. These indices may impact the development of B. tabaci and offer an explanation for the absence of the whitefly outdoors in the UK during the summer. Further analyses undertaken with climate projections suggest that in a 2–4°C warmer world this pest could pose a risk to outdoor UK crops in July and August. A clear south-north gradient can be demonstrated for these indices. Linking any possible northwards spread of B. tabaci populations outdoors in France with changes in these indices could therefore provide an important indicator of any change in the risks of outdoor populations of this species developing in the UK. The effectiveness of climate indices in pest risk analysis is compellingly demonstrated, and it is recommended that in-depth comparisons of climatic indices between areas of pest presence and absence are conducted in other situations where forecasting the risks of pest establishment are complex and challenging. [ABSTRACT FROM AUTHOR]

Background: The United Kingdom (UK) was the first European country to introduce a national immunisation program for shingles (2013–2014). That year, vaccination coverage ranged from 50 to 64% across the UK, but uptake has declined ever since. This study explored determinants of the acceptance of the shingles vaccine in the UK. Methods: Vaccinated and unvaccinated individuals, who were eligible for the last catch-up cohort of the 2014–2015 shingles vaccination campaign, were identified using the Clinical Practice Research Datalink (the National Health Service data research service) and invited to participate by their general practitioner (GP). An anonymised self-administered questionnaire was developed using the Health Belief Model as a theoretical framework, to collect data on demographic and socio-economic characteristics, health status, knowledge, influences, experiences and attitudes to shingles and the shingles vaccine. Multivariable logistic regression was used to identify the factors associated with vaccination. Physicians’ views concerning perceived barriers to vaccination were also assessed. Results: Of the 2,530 questionnaires distributed, 536 were returned (21.2%) from 69 general practices throughout the UK. The majority of responders were female (58%), lived in care homes (56%) and had completed secondary or higher education (88%). There were no differences between vaccinated and unvaccinated responders. Being offered the shingles vaccine by a GP/nurse (odds ratio (OR) = 2.3), and self-efficacy (OR = 1.2) were associated with being vaccinated (p<0.05). In contrast, previous shingles history (OR = 0.4), perceived barriers to vaccination (OR = 0.7) and perceived control of the disease (OR = 0.7) were associated with not being vaccinated against shingles (p<0.05). Less than half (44.0%) of GPs were aware of the local communication campaigns regarding shingles and the shingles vaccine. Conclusions: Socio-psychological factors largely influence shingles vaccination acceptance in this study. The results add to existing evidence that healthcare providers (HCPs) have a pivotal role against vaccine hesitancy. Campaigns focusing on GPs and accessible information offered to eligible members of the public can further enhance shingles vaccine uptake. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether implementation of comprehensive in-school eyecare results in measurable benefits for children and young people in terms of visual status, classroom behaviours and how well their visual needs are met. Design: School-based observational study. Participants & Methods: 200 pupils [mean age 10 years 9 months, 70% male, majority moderate (40%) or severe (35%) learning difficulty] of a special education school in the UK. A sector-agreed in-school eyecare framework including full eye examination and cycloplegic refraction, dispensing of spectacles (as appropriate) and written reporting of outcomes to parents/teachers was applied. Classroom behaviours were observed and recorded prior to, and after, the in-school eyecare. Surveys were employed to obtain visual histories from parents/teachers. School records and statutory documents were reviewed for diagnostic and learning disability classifications. Visual function and ocular health were profiled at baseline and significant visual deficits identified. Where such deficits were previously unrecognised, untreated or not compensated for (e.g. correction of refractive error, enlargement of educational material) they were recorded as ‘unmet visual need’. At follow-up, 2–5 months after initial (baseline) measures, eye examinations, parent/teacher surveys and behaviour observations were repeated. Follow-up measures were used to determine if measurable improvements were evident in visual function, ocular health, the level of unmet need and classroom behaviour following implementation of in-school eyecare. Results: 199 participants completed baseline and follow-up measures. 122 (61%) participants presented with at least one significant visual or ocular health deficit and 90 (45%) participants had at least one unmet visual need. Younger pupils and those with no previous history of eyecare were more likely to demonstrate unmet visual needs at baseline (OR 1.12 95% CI 1.03 to 1.21) p = 0.012; (OR 4.44 95% CI 1.38 to 14.29 p = 0.007 respectively). On follow-up, the number of pupils with unmet visual needs dropped significantly to 36 (18%) (McNemar’s test p<0.001). Visual and behavioural metrics of participants without significant visual deficits or whose visual needs were adequately addressed at baseline remained relatively unchanged between baseline and follow-up (Wilcoxon signed rank p>0.05). Where significant refractive deficits were corrected at follow-up, near visual acuity improved significantly (Wilcoxon signed rank p = 0.013), however, poor spectacle compliance was a persistent cause of unmet visual need. Off-task behaviour reduced significantly after actions to address unmet visual needs were communicated to parents and teachers (Wilcoxon signed rank p = 0.035). Conclusions: The present study demonstrates for the first time measurable visual and behaviour benefits to children in special education settings when they receive comprehensive in-school eye examinations, on-site spectacle dispensing and jargon-free reporting of outcomes to teachers and parents. [ABSTRACT FROM AUTHOR]

Effective perpetrator programmes should be embedded within a community response, engage all types of perpetrators and involve an educational approach that integrates the survivor’s voice. The Domestic Abuse Prevention Partnership (DAPP) is a transformative partnership based in the UK that aims to provide an integrated approach for perpetrators and survivors. This pragmatic mixed methods study was conducted to examine the baseline characteristics and individual outcomes of the main perpetrator programme within the DAPP. Applying a triangulation design, routine police re-offending aggregated data, pre- and post- perpetrator programme questionnaires, in-depth interviews with survivors, and focus-group discussions with perpetrators (clients) were integrated. Statistical analysis and thematic analysis were applied to quantitative and qualitative data, respectively. The majority of clients (47%) referred through the DAPP (n = 228) described wanting to make their relationship better as the main reason for engaging with the main perpetrators programme. Post-perpetrator programme questionnaires identified positive changes in both emotional behaviours and physical behaviours amongst clients, which were also supported by examples of improved relationships with their children described in survivor interviews. Three themes were described: first, making positive progress; second, impact of the children’s module; and concerns around sustaining new behaviours. Over the monitoring period, 1 in 5 clients were either suspected or convicted of domestic abuse crimes following the programme. This suggests that further maintenance of positive behaviours and reinforcements are required for some clients. Given that clients felt children were a strong motivating factor for completing a programme, it seemed paradoxical that no specialist services were made available for them. Future reiterations of the DAPP model should at least address how best to work with children in families where domestic abuse occurs. [ABSTRACT FROM AUTHOR]

Background: In October 2017, the United Kingdom Joint Committee on Vaccination and Immunisation (JCVI) recommended removal of one primary dose of the 13-valent pneumococcal conjugate vaccine (PCV13) from the existing 2+1 schedule (2, 4, 12 months). We conducted a mathematical modelling study to investigate the potential impact of a 1+1 (3, 12 month) schedule on invasive pneumococcal disease (IPD) and pneumococcal community-acquired pneumonia (CAP). Our results and those from a 1+1 immunogenicity study formed the key evidence reviewed by JCVI.Methods and Findings: We developed age-structured, dynamic, deterministic models of pneumococcal transmission in England and Wales to describe the impact on IPD of 7-valent PCV (PCV7; introduced in 2006) and PCV13 (introduced in 2010). Key transmission and vaccine parameters were estimated by fitting to carriage data from 2001/2002 and post-PCV IPD data to 2015, using vaccine coverage, mixing patterns between ages, and population data. We considered various models to investigate potential reasons for the rapid increase in non-PCV13 (non-vaccine serotype [NVT]) IPD cases since 2014. After searching a large parameter space, 500 parameter sets were identified with a likelihood statistically close to the maximum and these used to predict future cases (median, prediction range from 500 parameter sets). Our findings indicated that the emergence of individual NVTs with higher virulence resulting from ongoing replacement was likely responsible; the NVT increase was predicted to plateau from 2020. Long-term simulation results suggest that changing to a 1+1 schedule would have little overall impact, as the small increase in vaccine-type IPD would be offset by a reduction in NVT IPD. Our results were robust to changes in vaccine assumptions in a sensitivity analysis. Under the base case scenario, a change to a 1+1 schedule in 2018 was predicted to produce 31 (6, 76) additional IPD cases over five years and 83 (-10, 242) additional pneumococcal-CAP cases, with together 8 (-2, 24) additional deaths, none in children under 15 years. Long-term continuation with the 2+1 schedule, or changing to a 1+1, was predicted to sustain current reductions in IPD cases in under-64-year-olds, but cases in 65+-year-olds would continue to increase because of the effects of an aging population. Limitations of our model include difficulty in fitting to past trends in NVT IPD in some age groups and inherent uncertainty about future NVT behaviour, sparse data for defining the mixing matrix in 65+-year-olds, and the methodological challenge of defining uncertainty on predictions.Conclusions: Our findings suggest that, with the current mature status of the PCV programme in England and Wales, removing one primary dose in the first year of life would have little impact on IPD or pneumococcal CAP cases or associated deaths at any age. A reduction in the number of priming doses would improve programmatic efficiency and facilitate the introduction of new vaccines by reducing the number of coadministered vaccines given at 2 and 4 months of age in the current UK schedule. Our findings should not be applied to other settings with different pneumococcal epidemiology or with immature programmes and poor herd immunity. [ABSTRACT FROM AUTHOR]

Background: Funding shortages and an ageing population have increased pressures on state or insurance funded end of life care for older people. Across the world, policy debate has arisen about the potential role volunteers can play, working alongside health and social care professionals in the community to support and care for the ageing and dying. Aims: The authors examined self-reported levels of care for the elderly by the public in England, and public opinions of community volunteering concepts to care for the elderly at the end of life. In particular, claimed willingness to help and to be helped by local people was surveyed. Methods: A sample of 3,590 adults in England aged 45 or more from an online access panel responded to a questionnaire in late 2017. The survey data was weighted to be representative of the population within this age band. Key literature and formative qualitative research informed the design of the survey questionnaire, which was further refined after piloting. Results: Preferences for different models of community volunteering were elicited. There was a preference for ‘formal’ models with increased wariness of ‘informal’ features. Whilst 32% of adults said they ‘might join’ depending on whom the group helped, unsurprisingly more personal and demanding types of help significantly reduced the claimed willingness to help. Finally, willingness to help (or be helped) by local community carers or volunteers was regarded as less attractive than care being provided by personal family, close friends or indeed health and care professionals. Conclusion: Findings suggest that if community volunteering to care for elderly people at the end of life in England is to expand it may require considerable attention to the model including training for volunteers and protections for patients and volunteers as well as public education and promotion. Currently, in England, there is a clear preference for non-medical care to be delivered by close family or social care professionals, with volunteer community care regarded only as a back-up option. [ABSTRACT FROM AUTHOR]

We have now reached the genomics era within medicine; genomics is being used to personalise treatment, make diagnoses, prognoses, and predict adverse outcomes resulting from treatment with certain drugs. Genomic data is now abundant in healthcare, and the newly created profession of clinical bioinformaticians are responsible for its analysis. In the United Kingdom, clinical bioinformaticians are trained within a 3-year programme, integrating a work-based placement with a part-time Master’s degree. As this profession is still developing, trainees can feel isolated from their peers whom are located in other hospitals and can find it difficult to gain the mentorship that they require to complete their training. Building strong networks or communities of practice (CoPs) and allowing sharing of knowledge and experiences is one solution to addressing this isolation. Within the Master’s delivered at the University of Manchester, we have integrated group-centred problem-based learning (PBL) using real clinical case studies worked on during each course unit. This approach is combined with a flipped style of teaching providing access to online content in our Virtual Learning Environment before the course. The face-to-face teaching is used to focus on the application of the students’ knowledge to clinical case studies. In this study, we conducted semistructured interviews with 8 students, spanning 3 cohorts of students. We evaluated the effectiveness of this style of teaching and whether it had contributed to the formation of CoPs between our students. Our findings demonstrated that this style of teaching was preferred by our students to a more traditional lecture-based format and that the problem-based learning approach enabled the formation of CoPs within these cohorts. These CoPs are valuable in the development of this new profession and assist with the production of new guidelines and policies that are helping to professionalise this new group of healthcare scientists. [ABSTRACT FROM AUTHOR]

Introduction: The rapid rise in trade and use of NPS and the lack of information concerning their potential toxicity pose serious challenges to public health authorities across the world. Policy measures towards NPS taken so far have a special focus on their legal status, while the implementation of a public health strategy seems to be still missing. The aim of this study is to perform a general assessment of NPS-related policy (including regulatory measures and public health strategies) implemented by six European countries: Portugal, the Netherlands, Czech Republic, Poland, the United Kingdom and Sweden. Methods: Six EU countries were included in this scoping review study. Drug policies (including legal responses and public health strategies) were analysed. UNODC drug policy classification system was used as a benchmark, while path dependency approach was used for data analysis; a net of inter-dependencies between international, EU and national policies was highlighted. Results and discussion: The countries included in this study can be placed in a wide spectrum according to their formulation of drug policy, from Portugal and the UK that have specific legal responses to NPS but have differently focused on harm reduction strategies at one end, to Sweden whose drug-free society goal is not translated into a specific regulation of NPS at the other end. Conclusion: The findings of the study reveal limited development towards harmonisation of national drug policies–particularly with regard to NPS. To tackle the challenge presented by NPS, EU Member states have formulated legislation and public health strategies independently. National approaches to NPS are therefore in line with their already existing drug policies, reflecting cultural values towards substance abuse and national political interests, while the homogenization at an international level has so far mostly been focused on law enforcement and drugs use preventive strategies. [ABSTRACT FROM AUTHOR]

Unpaid work in the sciences is advocated as an entry route into scientific careers. We compared the success of UK science graduates who took paid or unpaid work six-months after graduation in obtaining a high salary or working in a STEM (Science, Technology Engineering and Mathematics) field 3.5 years later. Initially taking unpaid work was associated with lower earnings and lower persistence in STEM compared with paid work, but those using personal connections to obtain unpaid positions were as likely to persist in STEM as paid workers. Obtaining a position in STEM six months after graduation was associated with higher rates of persistence in STEM compared with a position outside STEM for both paid and unpaid workers, but the difference is considerably smaller for unpaid workers. Socio-economic inequality in the likelihood of obtaining entry in STEM by taking an unpaid position is a well-founded concern for scientific workforce diversity. [ABSTRACT FROM AUTHOR]

The relationship between child health, wellbeing and education demonstrates that healthier and happier children achieve higher educational attainment. An engaging curriculum that facilitates children in achieving their academic potential has strong implications for educational outcomes, future employment prospects, and health and wellbeing during adulthood. Outdoor learning is a pedagogical approach used to enrich learning, enhance school engagement and improve pupil health and wellbeing. However, its non-traditional means of achieving curricular aims are not yet recognised beyond the early years by education inspectorates. This requires evidence into its acceptability from those at the forefront of delivery. This study aimed to explore headteachers’, teachers’ and pupils’ views and experiences of an outdoor learning programme within the key stage two curriculum (ages 9–11) in South Wales, United Kingdom. We examine the process of implementation to offer case study evidence through 1:1 interviews with headteachers (n = 3) and teachers (n = 10) and focus groups with pupils aged 9–11 (n = 10) from three primary schools. Interviews and focus groups were conducted at baseline and six months into implementation. Schools introduced regular outdoor learning within the curriculum. This study found a variety of perceived benefits for pupils and schools. Pupils and teachers noticed improvements in pupils’ engagement with learning, concentration and behaviour, as well as positive impacts on health and wellbeing and teachers’ job satisfaction. Curriculum demands including testing and evidencing work were barriers to implementation, in addition to safety concerns, resources and teacher confidence. Participants supported outdoor learning as a curriculum-based programme for older primary school pupils. However, embedding outdoor learning within the curriculum requires education inspectorates to place higher value on this approach in achieving curricular aims, alongside greater acknowledgment of the wider benefits to children which current measurements do not capture. [ABSTRACT FROM AUTHOR]

Background: Children living in disadvantaged socio-economic circumstances (SEC) are more commonly victims of bullying, but pathways leading to social inequalities in being bullied are unclear. We assess how early life risk factors might mediate the increased risk of being bullied at age seven for children living in disadvantaged circumstances. Material and methods: Using data from 5,857 children in the UK Millennium Cohort Study (MCS) we calculate risk ratios (RR) for being bullied at age seven (child-reported), by household income quintile. Socially patterned risk factors for being bullied relating to social networks, family relationships and child characteristics from birth to age five were adjusted for to assess if they mediated any association between SEC and being bullied. Results: 48.6% of children reported having been bullied. Children living in the lowest income households were at 20% greater risk of being bullied compared to those from the highest (RR1.20, 95%CI 1.06,1.36). Controlling for social networks, family relationships and child characteristics attenuated the increased risk for children in low income households to aRR 1.19 (95%CI 1.05, 1.35), aRR 1.16 (95%CI 1.02,1.32) and aRR 1.13 (95%CI 1.00,1.28) respectively. Our final model adjusted for risk factors across all domains attenuated the RR by 45% (aRR 1.11,95%CI 0.97,1.26). Conclusions: About half of children reported being bullied by age seven with a clear social gradient. The excess risk in children growing up in disadvantaged circumstances was partially explained by differences in their early years relating to their social network, family relationships and the child’s own abilities and behaviours. Policies to reduce inequalities in these risk factors may also reduce inequalities in the risk of being bullied in childhood. [ABSTRACT FROM AUTHOR]

Independence at work is commonly considered a job resource which fosters motivation and employee well-being. Somewhat paradoxically, it is embedded in a relationship, and employees’ independence also hinges on their leaders’ willingness to grant it. Analyzing this resource as part of the leader-follower relationship can be useful in exploring its beneficial, ambivalent, or detrimental reciprocal effects. We present two Actor-Partner Interdependence Models (APIM) which analyze leaders’ and followers’ independence as antecedents, and work engagement and emotional exhaustion as outcomes. We test our models on 112 pairs of UK workers, finding a significant partner effect between leaders’ independence and followers’ exhaustion. Our findings confirm the utility of a dyadic perspective for investigating leadership and well-being at work, and suggest improvements for leadership training and measures fostering job well-being. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal symptoms in people living with HIV (PLWH) such as pain, joint stiffness, and fatigue are commonly reported. Prevalence rates of up to 45%, 79% and 88% respectively have been reported. However, very little is known about differences in prevalence and impact of musculoskeletal symptoms on physical functioning and quality of life of PLWH on effective combined antiretroviral treatment (cART) in high and low-resource settings. Methods: A cross-sectional study of PLWH on effective cART enrolled from two large urban clinics in the UK and Zambia was conducted in 2016. Eligible participants had no history of trauma to the joints within 4 weeks of recruitment, or documented evidence of previous rheumatic disease. Current musculoskeletal symptoms, functional ability, and health-related quality of life were evaluated using the health assessment (HAQ) and quality-of-life short form (SF-36) self-reported questionnaires. Results: 214 patients were enrolled (108:UK and 106:Zambia). Participants from Zambia were younger (47 vs 44 years) and had significantly lower CD4 counts (640 vs 439 cells/mL p = 0.018) compared to those from the UK, while the UK group had lived with HIV longer (11 vs 6 years; p<0.001) and reported more comorbidities than the Zambian group (66% vs 26%; p<0.001). Musculoskeletal pain was common in both groups (UK:69% vs Zambia:61% p = 0.263) but no significant differences in physical functional capacity between the groups were observed. However, the UK group had significantly worse quality of life measurements (general health, vitality, mental health, emotional, and social functioning) associated with musculoskeletal symptoms compared to the Zambian group (p<0.001). Conclusions: Musculoskeletal symptoms in PLWH from both the UK and Zambia were common. PLWH in the UK reported worse quality of life measures associated with musculoskeletal symptoms compared to those in Zambia, suggesting that factors such as mental health, patient expectations and multimorbidity might play a role in determining well-being and quality of life of PLWH with musculoskeletal symptoms. [ABSTRACT FROM AUTHOR]

Objective: To examine cross-sectional and prospective associations between perceived discrimination in daily life (based on a range of attributes), sexual orientation discrimination, and health and wellbeing in middle-aged and older lesbian, gay and bisexual (LGB) people. Methods: Data were from 304 LGB men and women aged 41–85 years participating in the English Longitudinal Study of Ageing. Perceived discrimination in daily life was reported in 2010/11. Participants could attribute their discrimination experience to characteristics including age, sex, race, physical disability, and sexual orientation. Self-rated health, limiting long-standing illness, depressive symptoms, quality of life, life satisfaction and loneliness were assessed in 2010/11 and 2016/17. Analyses adjusted for age, sex, ethnicity, partnership status and socioeconomic position. Results: Perceived discrimination in daily life was reported by 144 (47.4%) participants. Cross-sectionally, perceived discrimination in daily life was associated with increased odds of depressive symptoms (OR = 2.30, 95% CI 1.02 to 5.21), loneliness (OR = 3.37, 95% CI 1.60 to 7.10) and lower quality of life (B = -3.31, 95% CI -5.49 to -1.12). Prospectively, perceived discrimination in daily life was associated with increased odds of loneliness (OR = 3.12, 95% CI 1.08 to 8.99) and lower quality of life (B = -2.08, 95% CI -3.85 to -0.31) and life satisfaction (B = -1.92, 95% CI -3.44 to -0.39) over six-year follow-up. Effect sizes were consistently larger for participants who attributed experiences of discrimination to their sexual orientation compared with those who attributed experiences of discrimination to other reasons (e.g. age, sex, race). Conclusion: These results provide cross-sectional and prospective evidence of associations between perceived discrimination in daily life and health and wellbeing outcomes in middle-aged and older LGB adults in England. [ABSTRACT FROM AUTHOR]

The number of cancer-related emergency presentations and admissions has been steadily increasing in the UK. Drivers of this phenomenon are complex, multifactorial and interlinked. The main objective of this study was to understand the complexity of emergency hospital use in cancer patients. We conducted semi-structured interviews with 42 senior clinicians (20 doctors, 22 nurses) with diverse expertise and experience in caring for acutely ill cancer patients in the secondary care setting. Data analysis included thematic analysis and purposive text analysis to develop Causal Loop Diagrams. Our Causal Loop Diagrams represent an integrated understanding of the complex factors (13) influencing emergency hospital use in cancer patients. Eight factors formed five reinforcing feedback loops and therefore were high-leverage influences: Ability of patients and carers to self-care and cope; Effective and timely management of ambulatory care sensitive conditions by primary and community care; Sufficient and effective social care for patients and carers; Avoidable emergency hospital use; Bed capacity; Patients accessing timely appropriate specialist inpatient or ambulatory care; Prompt and effective management and prevention of acute episode; Timely and safe discharge with appropriate support. The loops show that reduction of avoidable hospital use helps relieve hospital bed pressure; improved bed capacity then has a decisive, positive influence on patient pathway and thus outcome and experience in the hospital; in turn, better in-hospital care and discharge help patients and carers self-care and cope better back home with better support from community-based health and social care services, which then reduces their future emergency hospital use. To optimise acute and emergency cancer care, it is also essential that patients, carers and other clinicians caring for cancer patients have prompt access to senior cancer specialists for advice, assessment, clinical decision and other support. The findings provide a useful framework and focus for service planners aiming to optimise care. [ABSTRACT FROM AUTHOR]

Given the high prevalence of common mental disorders (CMDs) and individuals living alone in the United Kingdom, the goal of this study using English nationally representative data was to examine the association between living alone and CMDs, and to identify potential mediating factors of this association. The data were drawn from the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. CMDs were assessed using the Clinical Interview Schedule-Revised (CIS-R), a questionnaire focusing on past week neurotic symptoms. The presence of CMDs was defined as a CIS-R total score of 12 and above. Multivariable logistic regression and mediation analyses were conducted to analyze the association between living alone and CMDs, and to identify mediators in this association. The prevalence of CMDs was higher in individuals living alone than in those not living alone in all survey years. Multivariable analysis showed a positive association between living alone and CMDs in all survey years (1993: odds ratio [OR] = 1.69; 2000: OR = 1.63; and 2007: OR = 1.88). Overall, loneliness explained 84% of the living alone-CMD association. Living alone was positively associated with CMDs. Interventions addressing loneliness among individuals living alone may be particularly important for the mental wellbeing of this vulnerable population. [ABSTRACT FROM AUTHOR]

Objective: To explore pregnant women’s preferences for birth setting in England. Design: Labelled discrete choice experiment (DCE). Setting: Online survey. Sample: Pregnant women recruited through social media and an online panel. Methods: We developed a DCE to assess women’s preferences for four hypothetical birth settings based on seven attributes: reputation, continuity of care, distance from home, time to see a doctor, partner able to stay overnight, chance of straightforward birth and safety for baby. We used a mixed logit model, with setting modelled as an alternative-specific constant, and conducted a scenario analysis to evaluate the impact of changes in attribute levels on uptake of birth settings. Main outcome measures: Women’s preferences for birth setting. Results: 257 pregnant women completed the DCE. All birth setting attributes, except ‘time to see doctor’, were significant in women’s choice (p<0.05). There was significant heterogeneity in preferences for some attributes. Changes to levels for ‘safety for the baby’ and ‘partner able to stay overnight’ were associated with larger changes from baseline uptake of birth setting. If the preferences identified were translated into the real-world context up to a third of those who reported planning birth in an obstetric unit might choose a midwifery unit assuming universal access to all settings, and knowledge of the differences between settings. Conclusions: We found that ‘safety for the baby’, ‘chance of a straightforward birth’ and ‘can the woman’s partner stay overnight following birth’ were particularly important in women’s preferences for hypothetical birth setting. If all birth settings were available to women and they were aware of the differences between them, it is likely that more low risk women who currently plan birth in OUs might choose a midwifery unit. [ABSTRACT FROM AUTHOR]

Background: In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare.Methods and Findings: Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world.Conclusions: Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free. [ABSTRACT FROM AUTHOR]

Quantifying the value of investment in medical research can inform decision-making on the prioritisation of research programmes. Existing methodologies to estimate the rate of return of medical research are inappropriate for early-phase translational research due to censoring of health benefits and time lags. A strategy to improve the process of translational research for patient benefit has been initiated as part of the UK National Institute for Health Research (NIHR) investment in Biomedical Research Centres (BRCs) in England. By providing a platform for partnership between universities, NHS trusts and industry, successful BRCs should reduce time lags within translational research whilst also providing an impetus for local economic growth through industry collaboration. We present a novel contribution in the assessment of early-phase biomedical research by estimating the impact of the Oxford Biomedical Research Centre (OxBRC) on income and job creation following the initial NIHR investment. We adopt a macroeconomic assessment approach using Input-Output Analysis to estimate the value of medical research in terms of income and job creation during the early pathway towards translational biomedical research. Inter-industry linkages are assessed by building a model economy for the South East England region to estimate the return on investment of the OxBRC. The results from the input-output model estimate that the return on investment in biomedical research within the OxBRC is 46%. Each £1 invested in the OxBRC generates an additional £0.46 through income and job creation alone. Multiplicative employment effects following a marginal investment in the OxBRC of £98m during the period 2007-2017 result in an estimated additional 196 full time equivalent positions being created within the local economy on top of direct employment within OxBRC. Results from input-output analyses can be used to inform the prioritisation of biomedical research programmes when compared against national minimum thresholds of investment. [ABSTRACT FROM AUTHOR]

Resistance to antimicrobials is one of the biggest challenges worldwide for public health. A key strategy for tackling this is ensuring judicious use of antimicrobials in human and veterinary medicine. Whilst there are many studies in human medicine investigating prescribing behaviour of doctors, there is limited work to understand what factors influence veterinarian prescribing behaviour. Veterinarians often prescribe antimicrobials to sheep and beef farmers in contexts other than at a clinical consultation, and decision-making behind this has not been explored. The aim of this study was to measure, for the first time, the influence of factors from social theories on veterinarians’ decision to prescribe antimicrobials to sheep and beef farmers without a clinical consultation, using a factorial survey approach. Respondents were presented with eight vignette scenarios, where a farmer asks for antimicrobials at the veterinary practice. Seven factors, identified from constructs of social theories, were included in the vignettes. Random intercept and random slope models were built to estimate the effects of the vignette factors and vet characteristics on the respondents’ willingness to prescribe ratings. A total of 306 surveys were completed. The vignette factors: case type, farmer relationship, other veterinarians in practice, time pressure, habit, willingness to pay, and confidence in the farmer, were significant in the decision to prescribe. Confidence in the farmer was the most influential vignette variable, and was included as a random slope effect. Respondent variables with significant influence on the decision to prescribe were agreeableness personality score, region of veterinary practice, and presence of a small animal department. These influential factors could be considered to target interventions in beef and sheep farm animal veterinary practice for improved antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

England’s national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective. [ABSTRACT FROM AUTHOR]

Many disciplines of scholarship are interested in the Relative Age Effect (RAE), whereby age-banding confers advantages on older members of the cohort over younger ones. Most research does not test this relationship in a manner consistent with theory (which requires a decline in frequency across the cohort year), instead resorting to non-parametric, non-directional approaches. In this article, the authors address this disconnect, provide an overview of the benefits associated with Poisson regression modelling, and two managerially useful measures for quantifying RAE bias, namely the Indices of Discrimination and Wastage. In a tutorial-like exposition, applications and extensions of this approach are illustrated using data on professional soccer players competing in the top two tiers of the “Big Five” European football leagues in the search to identify paragon clubs, leagues, and countries from which others may learn to mitigate this form of age-discrimination in the talent identification process. As with OLS regression, Poisson regression may include more than one independent variable. In this way we test competing explanations of RAE; control for unwanted sources of covariation; model interaction effects (that different clubs and countries may not all be subject to RAE to the same degree); and test for non-monotonic versions of RAE suggested in the literature. [ABSTRACT FROM AUTHOR]

Background: Men and women are increasingly likely to stay sexually active into later life, but research shows that sexual activity and satisfaction decrease with increasing age. Ill health and medical treatments may affect sexual activity but there is little research on why some older people with a health problem affecting their sexual activity are satisfied with their sex life, and others are not. Methods: A mixed method study integrating data and analyses from the third British National Survey of Sexual Attitudes and Lifestyles (n = 3343 aged 55–74 years) and from follow-up in-depth interviews with 23 survey participants who reported having a health condition or taking medication affecting their sex life. Results: Overall, 26.9% of men and 17.1% of women aged 55–74 reported having a health condition that affected their sex life. Among this group, women were less likely than men to be sexually active in the previous 6 months (54.3% vs 62.0%) but just as likely to be satisfied with their sex life (41.9% vs 42.1%). In follow-up interviews, participants sometimes struggled to tease out the effects of ill health from those of advancing age. Where effects of ill health were identified, they tended to operate through the inclination and capacity to be sexually active, the practical possibilities for doing so and the limits placed on forms of sexual expression. In close relationships partners worked to establish compensatory mechanisms, but in less close relationships ill health provided an excuse to stop sex or deterred attempts to resolve difficulties. Most fundamentally, ill health may influence whether individuals have a partner with whom to have sex. Conclusion: The data show complex interactions between health, lifestyle and relationship factors that affect sexual activity/satisfaction. When dealing with sexual problems in older people, practitioners need to take account of individual lifestyle, needs and preferences. [ABSTRACT FROM AUTHOR]

Access to reliable and timely information ensures that decision-makers can operate effectively. The motivations and challenges of parliamentarians and policy-makers in accessing evidence have been well documented in the policy literature. However, there has been little focus on research-providers. Understanding both the demand- and the supply-side of research engagement is imperative to enhancing impactful interactions. Here, we examine the broader experiences, motivations and challenges of UK-based research professionals engaging with research-users relevant to policy-making and scrutiny in the UK using a nationwide online questionnaire. The context of the survey partly involved contributing to the UK Evidence Information Service (EIS), a proposed rapid match-making service to facilitate interaction between parliamentary arenas that use evidence and research-providers. Our findings reveal, at least for this sub-sample who responded, that there are gender-related differences in policy-related experience, motivations, incentives and challenges for research professionals to contribute to evidence-informed decision-making through initiatives such as the EIS. Male and female participants were equally likely to have policy experience; however, males reported both significantly broader engagement with the research-users included in the survey and significantly higher levels of engagement with each research-user. Reported incentives for engagement included understanding what the evidence will be used for, guidance on style and content of contribution, and acknowledgement of contributions by the policymaker or elected official. Female participants were significantly more likely to select the guidance-related options. The main reported barrier was workload. We discuss how academia-policy engagement initiatives can best address these issues in ways that enhance the integration of research evidence with policy and practice across the UK. [ABSTRACT FROM AUTHOR]

Objectives: Age-related cognitive decline is a well-known phenomenon after age 65 but little is known about earlier changes and prior studies are based on relatively small samples. We investigated the impact of age on cognitive decline in the largest population sample to date including young to old adults. Method: Between 100,352 and 468,534 participants aged 38–73 years from UK Biobank completed at least one of seven self-administered cognitive functioning tests: prospective memory (PM), pairs matching (Pairs), fluid intelligence (FI), reaction time (RT), symbol digit substitution, trail making A and B. Up to 26,005 participants completed at least one of two follow-up assessments of PM, Pairs, FI and RT. Multivariable regression models examined the association between age (<45[reference], 45–49, 50–54, 55–59, 60–64, 65+) and cognition scores at baseline. Mixed models estimated the impact of age on cognitive decline over follow-up (~5.1 years). Results: FI was higher between ages 50 and 64 and lower at 65+ compared to <45 at baseline. Performance on all other baseline tests was lower with older age: with increasing age category, difference in test scores ranged from 2.5 to 7.8%(P<0.0001). Compared to <45 at baseline, RT and Pairs performance declined faster across all older age cohorts (3.0 and 1.2% change, respectively, with increasing age category, P<0.0001). Cross-sectional results yielded 8 to 12-fold higher differences in RT and Pairs with age compared to longitudinal results. Conclusions: Our findings suggest that declines in cognitive abilities <65 are small. The cross-sectional differences in cognition scores for middle to older adult years may be due in part to age cohort effects. [ABSTRACT FROM AUTHOR]

Background: The Healthy Living Pharmacy (HLP) project, launched in England, UK in 2009 was a novel approach of introducing public health services within community pharmacy to tackle local health inequalities. A national roll-out followed a reported successful pilot; subsequent local evaluations ensued. Objectives: To summarise reported outcomes and investigate contextual factors that indicate the presence, absence and maturity of implementation determinants, thus offering useful lessons to stakeholders in implementing future initiatives to achieve successful outcomes. Methods: A systematic review was conducted to identify all publications reporting on the HLP project. All HLP articles and conference abstracts were considered for inclusion and were assessed for methodological quality. The Consolidated Framework for Implementation Research (CFIR) was utilised to identify potential implementation determinants reported. Each article was then analysed to identify reported economic, humanistic or clinical outcomes. Results: The review included six peer-reviewed journal articles and 12 conference abstracts. Joanna Briggs Institute Qualitative Assessment and Review Instrument indicated deficiencies in methodological quality. Through adoption of the CFIR framework, the implementation determinants relevant to the implementation of HLP into community pharmacy were identified. A resonating issue emerged in that the absence of adopting an evidence-based implementation process limited the ability to capture meaningful outcome data. This resulted in a lack of evidence to support sustainability and the failure to address many of the well cited barriers, e.g. lack of awareness amongst patients, public and other healthcare professionals, and weak support for future investment in resource for training and dissemination. Conclusions: Healthcare systems are increasingly called on to adopt evidence-based interventions that improve quality, control costs, and maximize value, thus offering opportunity to accelerate the implementation of clinical pharmacy services and programs aimed at improving patient care. Interventions, such as the HLP project require focused efforts on implementation and evaluation of those implementation efforts to produce effective and lasting changes in complex health care systems. [ABSTRACT FROM AUTHOR]

Objective: To describe the opinions of British general practitioners regarding the potential of future technology to replace key tasks carried out in primary care. Design: Cross sectional online survey. Participants: 1,474 registered GPs in the United Kingdom. Main outcome measures: Investigators measured GPs’ opinions about the likelihood that future technology will be able to fully replace–not merely aid–the average GP in performing six primary care tasks; in addition, if GPs considered replacement for a particular task likely, the survey measured opinions about how many years from now this technological capacity might emerge. Results: A total of 720 (49%) responded to the survey. Most GPs believed it unlikely that technology will ever be able to fully replace physicians when it comes to diagnosing patients (489, 68%), referring patients to other specialists (444, 61%), formulating personalized treatment plans (441, 61%), and delivering empathic care (680, 94%). GPs were not in agreement about prognostics: one in two participants (380, 53%) considered it likely that technology will be fully capable of replacing physicians in performing this task, nearly half (187, 49%) of whom believed that the technological capacity will arise in the next ten years. Against these findings, the majority of GPs (578, 80%) believed it likely that future technology will be able to fully replace humans to undertake documentation; among them 261 (79%) estimated that the technological wherewithal would emerge during the next ten years. In general, age and gender were not correlated with opinions; nor was reported burnout and job satisfaction or whether GPs worked full time or part time. Conclusions: The majority of UK GPs in this survey were skeptical about the potential for future technology to perform most primary care tasks as well as or better than humans. However, respondents were optimistic that in the near future technology would have the capacity to fully replace GPs’ in undertaking administrative duties related to patient documentation. [ABSTRACT FROM AUTHOR]

Potato blackleg and soft rot caused by Pectobacterium and Dickeya species are among the most significant bacterial diseases affecting potato production globally. In this study we estimate the impact of future temperatures on establishment of non-indigenous but confirmed Pectobacterium and Dickeya species in Great Britain (GB). The calculations are based on probabilistic climate change data and a model fitted to disease severity data from a controlled environment tuber assay with the dominant potato blackleg and soft rot-causing species in GB (P. atrosepticum), and three of the main causative agents in Europe (P. carotovorum subsp. brasiliense, P. parmentieri, Dickeya solani). Our aim was to investigate if the European strains could become stronger competitors in the GB potato ecosystem as the climate warms, on the basis of their aggressiveness in tubers at different temperatures. Principally, we found that the tissue macerating capacity of all four pathogens will increase in GB under all emissions scenarios. The predominant Pectobacterium and Dickeya species in Europe are able to cause disease in tubers under field conditions currently seen in GB but are not expected to become widely established in the future, at least on the basis of their aggressiveness in tubers relative to P. atrosepticum under GB conditions. Our key take-home messages are that the GB potato industry is well positioned to continue to thrive via current best management practices and continued reinforcement of existing legislation. [ABSTRACT FROM AUTHOR]

Traditional economic interpretations have not been successful in explaining differences in saving rates across countries. One hypothesis is that savings respond to cultural specific social norms. The accepted view in economics so far is that culture does not have any effect on savings. We revisit this evidence using a novel dataset, which allows us to study the saving behavior of up to three generations of immigrants in the United Kingdom. Against the backdrop of existing evidence, we find that cultural preferences are an important explanation for cross-country differences in saving behavior, and their relevance persists up to three generations. [ABSTRACT FROM AUTHOR]

The financial crisis of 2007/08 precipitated a severe global economic downturn, typically referred to as the Great Recession. However, in the United Kingdom this period has been marked by limited change in national indicators of subjective well-being. We assessed the life satisfaction change in response to the Great Recession in a sample of British adults (N = 8,661). We first show that on average the life satisfaction change across the sample was limited. However, average effects may mask substantial amounts of heterogeneity in the data. We therefore explore beyond this average effect to determine whether there were disproportionate changes (losses and gains) in life satisfaction in key sub-groups of the population. We found that individuals experiencing unemployment, who lost income, were sick or disabled, experienced the greatest well-being reductions. Contrastingly the life satisfaction of many individuals did not greatly change following the Great Recession and for some it may have even improved. Our work highlights vulnerable groups that may need additional help during recession periods and also cautions against the over reliance on average measures of well-being. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to ‘DIY PrEP’, purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club. [ABSTRACT FROM AUTHOR]

Objective: Despite poor clinic communication and staff treatment being reported by donors, high rates of overall satisfaction are still reported in surveys. This study will evaluate the importance of communication and interaction between donors and fertility clinic staff in gamete donor care. Methods: We report on 120 egg and sperm donors’ responses to a UK-wide online satisfaction survey. The survey focused on donors’ interactions with fertility clinic staff pre-, during, and post- donation. Basic cross-tabulation was performed on the data using online survey software. Textual data was read and extracts identified, which illustrated and expanded on the findings from the numerical data. Diagrammatic modeling was also utilised to analyse the textual data, with particular focus to relationships between the donors and clinic staff, the main activities within the gamete donation process, and how these activities may affect donor satisfaction with the gamete donation process. Results: Donors expressed concern for the infertile couple and the resulting child; conveyed frustration at not receiving information on the expenses they could claim; felt lost in the system regarding the ease of making clinic appointments, and once made they were routinely not seen on time for these appointments. Donors also negatively commented on aftercare, the location and condition of the donation room, and information on contraception. In addition, Ovarian Hyperstimulation Syndrome was frequently reported, with these egg donors believing that clinic staff were not concerned with their physical or emotional well-being, but were instead disproportionately focused on extracting the eggs. Conclusions: The multifaceted notion of donors highlights the complexity inherent to the gamete donation process, which comprises various aspects of uncertainty in the donation system, and ambiguity in the donation process. Categorising donors as Altruist, Customer, and Patient, conveys the particular importance of staff communication and treatment in donor care. These categories are not mutually exclusive however, in that an individual donor may experience more than one of these perspectives during the course of their gamete donation journey. Finally, there were a number of exemplar cases, where donors reported high satisfaction throughout, and these correlated with them being given a single point of contact at the clinic. Subject to resource constraints, we suggest that this practice should be implemented throughout clinics in the UK, so that donors have access to dedicated clinic staff who not only support them emotionally and physically throughout the gamete donation process, but also ensure that communication is open, clear, timely, and consistent. [ABSTRACT FROM AUTHOR]

Background: Air pollution damages health by promoting the onset of some non-communicable diseases (NCDs), putting additional strain on the National Health Service (NHS) and social care. This study quantifies the total health and related NHS and social care cost burden due to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in England.Method and Findings: Air pollutant concentration surfaces from land use regression models and cost data from hospital admissions data and a literature review were fed into a microsimulation model, that was run from 2015 to 2035. Different scenarios were modelled: (1) baseline 'no change' scenario; (2) individuals' pollutant exposure is reduced to natural (non-anthropogenic) levels to compute the disease cases attributable to PM2.5 and NO2; (3) PM2.5 and NO2 concentrations reduced by 1 μg/m3; and (4) NO2 annual European Union limit values reached (40 μg/m3). For the 18 years after baseline, the total cumulative cost to the NHS and social care is estimated at £5.37 billion for PM2.5 and NO2 combined, rising to £18.57 billion when costs for diseases for which there is less robust evidence are included. These costs are due to the cumulative incidence of air-pollution-related NCDs, such as 348,878 coronary heart disease cases estimated to be attributable to PM2.5 and 573,363 diabetes cases estimated to be attributable to NO2 by 2035. Findings from modelling studies are limited by the conceptual model, assumptions, and the availability and quality of input data.Conclusions: Approximately 2.5 million cases of NCDs attributable to air pollution are predicted by 2035 if PM2.5 and NO2 stay at current levels, making air pollution an important public health priority. In future work, the modelling framework should be updated to include multi-pollutant exposure-response functions, as well as to disaggregate results by socioeconomic status. [ABSTRACT FROM AUTHOR]

Slaughterhouse surveillance through post-mortem meat inspection provides an important mechanism for detecting bovine tuberculosis (bTB) infections in cattle herds in Great Britain (GB), complementary to the live animal skin test based programme. We explore patterns in the numbers of herd breakdowns detected through slaughterhouse surveillance and develop a Bayesian hierarchical regression model to assess the associations of animal-level factors with the odds of an infected animal being detected in the slaughterhouse, allowing us to highlight slaughterhouses that show atypical patterns of detection. The analyses demonstrate that the numbers and proportions of breakdowns detected in slaughterhouses increased in GB over the period of study (1998–2013). The odds of an animal being a slaughterhouse case was strongly associated with the region of the country that the animal spent most of its life, with animals living in high-frequency testing areas of England having on average 21 times the odds of detection compared to animals living in Scotland. There was also a strong effect of age, with animals slaughtered at > 60 months of age having 5.3 times the odds of detection compared to animals slaughtered between 0–18 months of age. Smaller effects were observed for cattle having spent time on farms with a history of bTB, quarter of the year that the animal was slaughtered, movement and test history. Over-and-above these risks, the odds of detection increased by a factor of 1.1 for each year of the study. After adjustment for these variables, there were additional variations in risk between slaughterhouses and breed. Our framework has been adopted into the routine annual surveillance reporting carried out by the Animal Plant Health Agency and may be used to target more detailed investigation of meat inspection practices. [ABSTRACT FROM AUTHOR]