Inequalities in local government spending on cultural, environmental and planning services: a time-trend analysis in England, Scotland, and Wales.

BACKGROUND: Local government provides Cultural, Environmental, and Planning (CEP) services, such as parks, libraries, and waste collection, that are vital for promoting health and wellbeing. There have been significant changes to the funding of these services over the past decade, most notably due to the UK government's austerity programme. These changes have not affected all places equally. To understand potential impacts on health inequalities, we investigated geographical patterning of recent CEP spending trends. METHODS: We conducted a time trend analysis using routinely available data on local government expenditure. We used generalised estimating equations to determine how expenditure trends varied across 378 local authorities (LAs) in Great Britain between 2009/10 and 2018/19 on the basis of country, deprivation, rurality, and local government structure. We investigated the gross expenditure per capita on CEP services, and the CEP expenditure as a proportion of total local authority budgets. We present the estimated annual percentage change in these spend measures. RESULTS: Expenditure per capita for CEP services reduced by 36% between 2009/10 and 2018/19. In England, the reduction in per capita spending was steepest in the most deprived quintile of areas, falling by 7.5% [95% CI: 6.0, 8.9] per year, compared to 4.5% [95% CI: 3.3, 5.6] per year in the least deprived quintile. Budget cuts in Scotland and Wales have been more equitable, with similar trends in the most and least deprived areas. Welsh LAs have reduced the proportion of total LA budget spent on CEP services the most (-4.0% per year, 95% CI: -5.0 to -2.9), followed by Scotland (-3.0% per year, 95% CI: -4.2 to -1.7) then England (-1.4% per year, 95% CI: -2.2 to -0.6). In England, rural and unitary LAs reduced their share of spending allocated to CEP more than urban and two-tier structured LAs, respectively. CONCLUSION: Funding for cultural, environmental and planning services provided by local government in the UK has been cut dramatically over the last decade, with clear geographical inequalities. Local areas worst affected have been those with a higher baseline level of deprivation, those with a single-tier local government structure, and English rural local authorities. The inequalities in cuts to these services risk widening geographical inequalities in health and wellbeing.

Mental health impact of cuts to local government spending on cultural, environmental and planning services in England: a longitudinal ecological study.

BACKGROUND: Over the past decade, there have been significant and unequal cuts to local authority (LA) budgets, across England. Cultural, environmental and planning (CEP) budgets have been cut by 17% between 2011 and 2019. This funding supports services such as parks, leisure centres, community development and libraries, all of which have potential to influence population mental health. We therefore investigated whether cuts to CEP services have affected mental health outcomes and the extent to which they have contributed to mental health inequalities between areas. METHODS: Using fixed effects regression applied to longitudinal LA-level panel data in England, we assessed whether trends in CEP spend were associated with trends in mental health outcomes, between 2011 and 2019. The exposure was CEP spend and the primary outcome was the LA-average Small Area Mental Health Index (SAMHI). Additionally, we considered subcategories of CEP spend as secondary exposures, and antidepressant prescription rate and self-reported anxiety levels as secondary outcomes, both aggregated to LA-level. We adjusted all models for confounders and conducted subgroup analysis to examine differential mental health effects of spending cuts based on the level of area deprivation. RESULTS: The average decrease in CEP spend of 15% over the period was associated with a 0.036 (95% CI: 0.005, 0.067) increase in SAMHI score, indicating worsening mental health. Amongst subcategories of CEP spending, cuts to planning and development services impacted mental health trends the most, with a 15% reduction in spend associated with a 0.018 (95% CI: 0.005, 0.031) increase in the SAMHI score. The association between cuts in CEP and deteriorating mental health was greater in more affluent areas. CONCLUSION: Cuts to spending on cultural, environmental, planning and development services were associated with worsening population mental health in England. Impacts were driven by cuts to planning and development services in particular. Reinvesting in these services may contribute to improved public mental health.

Impact of External Quality Assurance on the Quality of Xpert MTB/RIF Testing in Viet Nam.

Following the endorsement of the Xpert MTB/RIF assay (Cepheid, Sunnyvale, CA, USA) by the World Health Organization (WHO) in 2010, Viet Nam's National Tuberculosis Control Program (NTP) began using GeneXpert instruments in NTP laboratories. In 2013, Viet Nam's NTP implemented an Xpert MTB/RIF external quality assurance (EQA) program in collaboration with the U.S. Centers for Disease Control and Prevention (CDC) and the Foundation for Innovative New Diagnostics (FIND). Proficiency-testing (PT) panels comprising five dried tube specimens (DTS) were sent to participating sites approximately twice a year from October 2013 to July 2016. The number of enrolled laboratories increased from 22 to 39 during the study period. Testing accuracy was assessed by comparing reported and expected results; percentage scores were assigned; and feedback reports were provided to sites. On-site evaluation (OSE) was conducted for underperforming laboratories. The results from the first five rounds demonstrate the positive impact of PT and targeted OSE visits on testing quality. On average, for every additional round of feedback, the odds of achieving PT scores of ≥80% increased 2.04-fold (95% confidence interval, 1.39- to 3.00-fold). Future work will include scaling up PT to all sites and maintaining the performance of participating laboratories while developing local panel production capacity.

Implications of child poverty reduction targets for public health and health inequalities in England: a modelling study between 2024 and 2033.

BACKGROUND: We investigated the potential impacts of child poverty (CP) reduction scenarios on population health and health inequalities in England between 2024 and 2033. METHODS: We combined aggregate local authority-level data with published and newly created estimates on the association between CP and the rate per 100 000 of infant mortality, children (aged <16) looked after, child (aged <16) hospitalisations for nutritional anaemia and child (aged <16) all-cause emergency hospital admissions. We modelled relative, absolute (per 100 000) and total (per total population) annual changes for these outcomes under three CP reduction scenarios between 2024 and 2033-low-ambition (15% reduction), medium-ambition (25% reduction) and high-ambition (35% reduction)-compared with a baseline CP scenario (15% increase). Annual changes were aggregated between 2024 and 2033 at national, regional and deprivation (IMD tertiles) levels to investigate inequalities. RESULTS: All CP reduction scenarios would result in substantial improvements to child health. Meeting the high-ambition reduction would decrease total cases of infant mortality (293; 95% CI 118 to 461), children looked after (4696; 95% CI 1987 to 7593), nutritional anaemia (458, 95% CI 336 to 574) and emergency admissions (32 650; 95% CI 4022 to 61 126) between 2024 and 2033. Northern regions (eg, North East) exhibited the greatest relative and absolute benefit. The most deprived tertile would experience the largest relative, absolute and total benefit; under high-ambition reduction, total infant mortality cases were predicted to fall by 126 (95% CI 51 to 199) in the most deprived tertile compared with 71 (95% CI 29 to 112) in the least between 2024 and 2033. CONCLUSIONS: Achieving reductions in CP could substantially improve child health and reduce health inequalities in England.

Child poverty and children entering care in England, 2015-20: a longitudinal ecological study at the local area level.

BACKGROUND: Children in care face adverse health outcomes throughout their life course compared with their peers. In England, over the past decade, the stark rise in the number of cared-for children has coincided with rising child poverty, a key risk factor for children entering care. We aimed to assess the contribution of recent trends in child poverty to trends in care entry. METHODS: In this longitudinal, ecological study of 147 local authorities in England, we linked data from the Department for Work and Pensions and HM Revenue & Customs on the proportion of children younger than 16 years living in families with income less than 60% of the contemporary national median income, before housing costs, with Department for Education data on rates of children younger than 16 years entering care. Using within-between regression models, and controlling for employment trends, we estimated the association of changing child poverty rates with changing care entry rates within different areas. Our primary outcome was the annual rate of children younger than 16 years starting to be looked after by local authorities in England. FINDINGS: Between 2015 and 2020, controlling for employment rates, a 1 percentage point increase in child poverty was associated with an additional five children entering care per 100 000 children (95% CI 2-8). We estimate that, over the study period, 8·1% of the total number of children under the age of 16 entering care (5·0-11·3) were linked to rising child poverty, equivalent to 10 351 (6447-14 567) additional children. INTERPRETATION: We report evidence that rising child poverty rates might be contributing to an increase in children entering care. Children's exposure to poverty creates and compounds adversity, driving poor health and social outcomes in later life. National anti-poverty policies are key to tackling adverse trends in children's care entry in England. FUNDING: National Institute for Health Research (NIHR) School for Public Health Research, NIHR Public Health Policy Research Unit, Swedish Research Council, Wellcome Trust, Medical Research Council, and NIHR Applied Research Collaboration North West Coast.

Impact of cuts to local government spending on Sure Start children's centres on childhood obesity in England: a longitudinal ecological study.

BACKGROUND: Childhood obesity is rising in disadvantaged areas in England. Sure Start children's centres provide community-based services for children <5 years and their parents, including many services that can support healthy weight, directly or indirectly. Since 2010, austerity-driven cuts to local authority (LA) budgets have led to substantially reduced public expenditure on Sure Start services. We assessed whether childhood obesity prevalence has increased more since 2010 in those areas in England that experienced greater cuts to spending on Sure Start. METHODS: This longitudinal ecological study covers the period 2010/2011-2017/2018. Our exposure was LA expenditure on Sure Start, using Department for Education data. Our main outcome was LA obesity prevalence at age 4-5 years, using National Child Measurement Programme data. We used fixed-effects panel regression to quantify the association between change in spending and change in the prevalence of childhood obesity. RESULTS: Spending on Sure Start children's centres decreased on average 53% over the study period, with deeper cuts in more deprived LAs. Each 10% spending cut was associated with a 0.34% relative increase in obesity prevalence the following year (95% CI 0.15% to 0.53%). We estimated there were an additional 4575 children with obesity (95% CI 1751 to 7399) and 9174 overweight or obese (95% CI 2689 to 15 660) compared with expected numbers had funding levels been maintained. CONCLUSIONS: Cuts to spending on Sure Start children's centres were associated with increased childhood obesity. With deprived areas experiencing bigger spending cuts, reinvesting in these services may, alongside wider benefits for child development, contribute to reducing inequalities in childhood obesity.

Local government funding and life expectancy in England: a longitudinal ecological study.

BACKGROUND: Since 2010, large reductions in funding for local government services have been introduced in England. These reductions in funding have potentially led to reduced provision of health-promoting public services. We aimed to investigate whether areas that showed a greater decline in funding also had more adverse trends in life expectancy and premature mortality. METHODS: In this longitudinal ecological study, we linked annual data from the Ministry of Housing, Communities, and Local Government on local government revenue expenditure and financing to 147 upper-tier local authorities in England between 2013 and 2017 with data from Public Health England, on male and female life expectancy at birth, male and female life expectancy at age 65 years, and premature (younger than 75 years) all-cause mortality rate for male and female individuals. Local authorities were excluded if their populations were too small or if changes in boundaries meant consistent data were not available. Using multivariable fixed-effects panel regression models, and controlling for local socioeconomic conditions, we estimated whether changes in local funding from 2013 were associated with changes in life expectancy and premature mortality. We included a set of alternative model specifications to test the robustness of our findings. FINDINGS: Between 2013 and 2017, mean per-capita central funding to local governments decreased by 33% or £168 per person (range -£385 to £1). Each £100 reduction in annual per person funding was associated over the study period 2013-17 with an average decrease in life expectancy at birth of 1·3 months (95% CI 0·7-1·9) for male individuals and 1·2 months (0·7-1·7) for female individuals; for life expectancy at age 65 years, the results show a decrease of 0·8 months (0·3-1·3) for male individuals and 1·1 months (0·7-1·5) for female individuals. Funding reductions were greater in more deprived areas and these areas had the worst changes in life expectancy. We estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women. Overall reductions in funding during this period were associated with an additional 9600 deaths in people younger than 75 years in England (3800-15 400), an increase of 1·25%. INTERPRETATION: Our findings indicate that cuts in funding for local government might in part explain adverse trends in life expectancy. Given that more deprived areas showed greater reductions in funding, our analysis suggests that inequalities have widened. Since the pandemic, strategies to address these adverse trends in life expectancy and reduce health inequalities could prioritise reinvestment in funding for local government services, particularly within the most deprived areas of England. FUNDING: National Institute for Health Research (NIHR) School for Public Health Research, NIHR Applied Research Collaboration North East and North Cumbria, NIHR Applied Research Collaboration North West Coast and Medical Research Council.

Priorities for the child public health response to the COVID-19 pandemic recovery in England.

Child health is at risk from the unintended consequences of the COVID-19 response and will suffer further unless it is given proper consideration. The pandemic can be conceived as a systemic shock to the wider determinants of child health, with impacts on family functioning and income, access to healthcare and education. This article outlines COVID-19 impacts on children in England. Key priorities relate to the diversion of healthcare during lockdown; interruption and return to schooling; increased health risks and long-term impacts on child poverty and social inequalities. We provide an overview of mitigation strategies and policy recommendations aimed to assist both national and local professionals across child health, education, social care and related fields to inform the policy response.

Trends in inequalities in Children Looked After in England between 2004 and 2019: a local area ecological analysis.

OBJECTIVE: To assess trends in inequalities in Children Looked After (CLA) in England between 2004 and 2019, after controlling for unemployment, a marker of recession and risk factor for child maltreatment. DESIGN: Longitudinal local area ecological analysis. SETTING: 150 English upper-tier local authorities. PARTICIPANTS: Children under the age of 18 years. PRIMARY OUTCOME MEASURE: The annual age-standardised rate of children starting to be looked after (CLA rate) across English local authorities, grouped into quintiles based on their level of income deprivation. Slope indices of inequality were estimated using longitudinal segmented mixed-effects models, controlling for unemployment. RESULTS: Since 2008, there has been a precipitous rise in CLA rates and a marked widening of inequalities. Unemployment was associated with rising CLA rates: for each percentage point increase in unemployment rate, an estimated additional 9 children per 100 000 per year (95% CI 6 to 11) became looked after the following year. However, inequalities increased independently of the effect of unemployment. Between 2007 and 2019, after controlling for unemployment, the gap between the most and least deprived areas increased by 15 children per 100 000 per year (95% CI 4 to 26) relative to the 2004-2006 trend. CONCLUSIONS: The dramatic increase in the rate of children starting to be looked after has been greater in poorer areas and in areas more deeply affected by recession. But trends in unemployment do not explain the decade-long rise in inequalities, suggesting that other socioeconomic factors, including rising child poverty and reduced spending on children's services, may be fuelling inequalities. Policies to safely reduce the CLA rate should urgently address the social determinants of child health and well-being.

Antenatal care among Palestine refugees in Jordan: factors associated with UNRWA attendance.

BACKGROUND: Maternal and neonatal mortality is a global issue acknowledged by the Sustainable Development Goals (SDGs). Adequate ante-natal care (ANC) is pivotal to reducing these mortality rates, while understanding why women don't attend ANC is crucial to addressing the SDGs. AIMS: Using routine primary health care data to determine the factors associated with inadequate attendance by Palestine refugees (PR) to ANC seeking facilities provided by the United Nations Relief and Works agency for Palestine Refugees in the Near East (UNRWA), Jordan. METHODS: A backwards logistic regression model incorporating non-health system factors and health system factors, was performed using UNRWA data. RESULTS: A younger age of women was associated with inadequate ANC visits (P = 0.0009) in the non-health systems model. For health system factors, pregnancy risk status, having a gynaecologist review and the health centre attended were factors found to be significantly associated with ANC attendance (P < 0.0001). CONCLUSIONS: Understanding the health system factors associated with ANC attendance can lead to changes and improvements in UNRWA's operational policies.

Strengthening Quality of Tuberculosis Laboratories Toward Accreditation in Viet Nam.

OBJECTIVES: Early diagnosis of tuberculosis (TB) and multidrug-resistant TB (MDR-TB) is a priority for Viet Nam's National TB Control Programme. In many laboratories, quality systems are weak; few have attained accreditation. We implemented a structured training and mentoring program for TB laboratories and measured impact on quality. METHODS: Six TB culture laboratories implemented the Strengthening TB Laboratory Management Towards Accreditation (TB SLMTA) program, consisting of three training workshops and on-site mentoring between workshops to support improvement projects. Periodic audits, using standardized checklists, monitored laboratories' progress toward accreditation readiness. RESULTS: At baseline, all six laboratories achieved a zero-star level. At exit, five laboratories attained three stars and another one star. Overall checklist scores increased by 44.2% on average, from 29.8% to 74.0%; improvements occurred across all quality system essentials. CONCLUSIONS: The program led to improved quality systems. Sites should be monitored to ensure sustainability of improvements and country capacity expanded for national scaleup.