Ethnic inequalities among NHS staff in England: workplace experiences during the COVID-19 pandemic.

OBJECTIVES: This study aims to determine how workplace experiences of National Health Service (NHS) staff varied by ethnicity during the COVID-19 pandemic and how these experiences are associated with mental and physical health at the time of the study. METHODS: An online Inequalities Survey was conducted by the Tackling Inequalities and Discrimination Experiences in Health Services study in collaboration with NHS CHECK. This Inequalities Survey collected measures relating to workplace experiences (such as personal protective equipment (PPE), risk assessments, redeployments and discrimination) as well as mental health (Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder 7 (GAD-7)), and physical health (PHQ-15) from NHS staff working in the 18 trusts participating with the NHS CHECK study between February and October 2021 (N=4622). RESULTS: Regression analysis of this cross-sectional data revealed that staff from black and mixed/other ethnic groups had greater odds of experiencing workplace harassment (adjusted OR (AOR) 2.43 (95% CI 1.56 to 3.78) and 2.38 (95% CI 1.12 to 5.07), respectively) and discrimination (AOR 4.36 (95% CI 2.73 to 6.96) and 3.94 (95% CI 1.67 to 9.33), respectively) compared with white British staff. Staff from black ethnic groups also had greater odds than white British staff of reporting PPE unavailability (AOR 2.16 (95% CI 1.16 to 4.00)). Such workplace experiences were associated with negative physical and mental health outcomes, though this association varied by ethnicity. Conversely, understanding employment rights around redeployment, being informed about and having the ability to inform redeployment decisions were associated with lower odds of poor physical and mental health. CONCLUSIONS: Structural changes to the way staff from ethnically minoritised groups are supported, and how their complaints are addressed by leaders within the NHS are urgently required.

A quantitative approach to the intersectional study of mental health inequalities during the COVID-19 pandemic in UK young adults.

PURPOSE: Mental health inequalities across social identities/positions during the COVID-19 pandemic have been mostly reported independently from each other or in a limited way (e.g., at the intersection between age and sex or gender). We aim to provide an inclusive socio-demographic mapping of different mental health measures in the population using quantitative methods that are consistent with an intersectional perspective. METHODS: Data included 8,588 participants from two British cohorts (born in 1990 and 2000-2002, respectively), collected in February/March 2021 (during the third UK nationwide lockdown). Measures of anxiety and depressive symptomatology, loneliness, and life satisfaction were analysed using Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) models. RESULTS: We found evidence of large mental health inequalities across intersectional strata. Large proportions of those inequalities were accounted for by the additive effects of the variables used to define the intersections, with some of the largest gaps associated with sexual orientation (with sexual minority groups showing substantially worse outcomes). Additional inequalities were found by cohort/generation, birth sex, racial/ethnic groups, and socioeconomic position. Intersectional effects were observed mostly in intersections defined by combinations of privileged and marginalised social identities/positions (e.g., lower-than-expected life satisfaction in South Asian men in their thirties from a sexual minority and a disadvantaged childhood social class). CONCLUSION: We found substantial inequalities largely cutting across intersectional strata defined by multiple co-constituting social identities/positions. The large gaps found by sexual orientation extend the existing evidence that sexual minority groups were disproportionately affected by the pandemic. Study implications and limitations are discussed.

Ethnic inequalities during clinical placement: A qualitative study of student nurses' experiences within the London National Health Service.

AIM: To understand how student nurse experiences on clinical placement, within National Health Service (NHS) hospitals, differ for ethnic minority and White British groups. DESIGN: A qualitative thematic analysis with an inductive approach. METHODS: Data from semi-structured interviews with 21 London (United Kingdom) hospital-based student nurses were examined using thematic analysis. Participants were interviewed as part of the Tackling Inequalities and Discrimination Experiences in Health Services (TIDES) study and asked about their experiences during clinical placement. RESULTS: Five main themes were identified: (1) Role of mentors, (2) Discrimination and unfair treatment, (3) Speaking up/out, (4) Career progression, and (5) Consequences of adverse experiences. All themes were linked, with the social dynamics and workplace environment (referred to as "ward culture") providing a context that normalizes mistreatment experienced by nursing students. Students from ethnic minority backgrounds reported racism as well as cultural and/or religious microaggressions. While being valued for their race and ethnicity, White British students also experienced discrimination and inequity due to their age, sex, gender, and sexual orientation. Students from both White British and ethnic minority groups acknowledged that being treated badly was a barrier to career progression. Ethnic minority students also noted the lack of diverse representation within senior nursing positions discouraged career progression within the UK NHS. CONCLUSION: These initial experiences of inequality and discrimination are liable to shape a student's perspective of their profession and ability to progress within nursing. The NHS is responsible for ensuring that student nurses' developmental opportunities are equal, irrespective of ethnicity. IMPACT: Ward culture is perpetuated by others who normalize mistreatment and concurrently disadvantage ethnic minority students, making them feel unvalued. This in turn impacts both staff retention and career progression within the NHS. Training assessors should be aware of the existing culture of discrimination within clinical placements and work to eradicate it.

Variations by ethnicity in referral and treatment pathways for IAPT service users in South London.

BACKGROUND: The Improving Access to Psychological Therapies (IAPT) programme aims to provide equitable access to therapy for common mental disorders. In the UK, inequalities by ethnicity exist in accessing and receiving mental health treatment. However, limited research examines IAPT pathways to understand whether and at which points such inequalities may arise. METHODS: This study examined variation by ethnicity in (i) source of referral to IAPT services, (ii) receipt of assessment session, (iii) receipt of at least one treatment session. Routine data were collected on service user characteristics, referral source, assessment and treatment receipt from 85 800 individuals referred to South London and Maudsley NHS Foundation Trust IAPT services between 1st January 2013 and 31st December 2016. Multinomial and logistic regression analysis was used to assess associations between ethnicity and referral source, assessment and treatment receipt. Missing ethnicity data (18.5%) were imputed using census data and reported alongside a complete case analysis. RESULTS: Compared to the White British group, Black African, Asian and Mixed ethnic groups were less likely to self-refer to IAPT services. Black Caribbean, Black Other and White Other groups are more likely to be referred through community services. Almost all racial and minority ethnic groups were less likely to receive an assessment compared to the White British group, and of those who were assessed, all racial and ethnic minority groups were less likely to be treated. CONCLUSIONS: Racial and ethnic minority service users appear to experience barriers to IAPT care at different pathway stages. Services should address potential cultural, practical and structural barriers.

Multimorbidity and fit note receipt in working-age adults with long-term health conditions.

BACKGROUND: Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population. METHODS: Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017. RESULTS: We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95). CONCLUSIONS: Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.

A comparison of single and intersectional social identities associated with discrimination and mental health service use: data from the 2014 Adult Psychiatric Morbidity Survey in England.

Inequities in mental health service use (MHSU) and treatment are influenced by social stratification processes linked to socially contextualised interactions between individuals, organisations and institutions. These complex relations underpin observed inequities and their experience by people at the intersections of social statuses. Discrimination is one important mechanism influencing such differences. We compared inequities in MHSU/treatment through single and intersectional status analyses, accounting for need. We assessed whether past-year discrimination differentially influences MHSU/treatment across single and intersecting statuses. Data came from a population survey (collected 2014-2015) nationally representative of English households (N = 7546). We used a theory and datadriven approach (latent class analysis) which identified five intersectional groups in the population comprising common combinations of social statuses. Single status analyses identified characteristics associated with MHSU/treatment (being a sexual minority (adjusted odds ratio (AOR) 1.65 95% CI:1.09-2.50), female (AOR 1.71, 95% CI:1.45-2.02), economically inactive (AOR 2.02, 95% CI:1.05-3.90), in the most deprived quintile (AOR 1.33, 95% CI:1.02-1.74), and Black (AOR 0.36 95% CI:0.20-0.66)). Intersectional analyses detected patterns not apparent from single status analyses. Compared to the most privileged group ("White British, highly educated, employed, high social class"), "Retired White British" had greater odds of MHSU/treatment (AOR 1.88, 95% CI:1.53-2.32) while "Employed migrants" had lower odds (AOR 0.39, 95% CI:0.27-0.55). Past-year discrimination was associated with certain disadvantaged social statuses and greater MHSU/treatment but-except for sexual minorities-adjusting for discrimination had little influence using either analytic approach. Observing patterns only by single social statuses masks potentially unanticipated and contextually varying inequities. The latent class approach offers policy-relevant insights into patterns and mechanisms of inequity but may mask other key intersectional patterns by statuses less common or under represented in surveys (e.g. UK-born ethnic minority groups). We propose multiple, context-relevant, theory-driven approaches to intersectional understanding of mental health inequalities.

Race, ethnicity and COVID-19 vaccination: a qualitative study of UK healthcare staff.

OBJECTIVE: COVID-19-related inequities experienced by racial and ethnic minority groups including healthcare professionals mirror wider health inequities, which risk being perpetuated by lower uptake of vaccination. We aim to better understand lower uptake among racial and ethnic minority staff groups to inform initiatives to enhance uptake. DESIGN: Twenty-five semi-structured interviews were conducted (October 2020-January 2021) with UK-based healthcare staff. Data were inductively and thematically analysed. RESULTS: Vaccine decision-making processes were underpinned by an overarching theme, 'weighing up risks of harm against potential benefits to self and others'. Sub-themes included 'fear of harm', 'moral/ethical objections', 'potential benefits to self and others', 'information and misinformation', and 'institutional or workplace pressure'. We identified ways in which these were weighted more heavily towards vaccine hesitancy for racial and ethnic minority staff groups influenced by perceptions about institutional and structural discrimination. This included suspicions and fear around institutional pressure to be vaccinated, racial injustices in vaccine development and testing, religious or ethical concerns, and legitimacy and accessibility of vaccine messaging and communication. CONCLUSIONS: Drawing on a critical race perspective, we conclude that acknowledging historical and contemporary abuses of power is essential to avoid perpetuating and aggravating mistrust by de-contextualising hesitancy from the social processes affecting hesitancy, undermining efforts to increase vaccine uptake.

"They created a team of almost entirely the people who work and are like them": A qualitative study of organisational culture and racialised inequalities among healthcare staff.

Racially and ethnically minoritised healthcare staff groups disproportionately experience and witness workplace discrimination from patients, colleagues and managers. This is visible in their under-representation at senior levels and over-representation in disciplinary proceedings and is associated with adversities such as greater depression, anxiety, somatic symptoms, low job satisfaction and sickness absence. In the UK, little progress has been made despite the implementation of measures to tackle racialised inequities in the health services. So, what is it about the health service organisational context which shapes and maintains such inequities, and what role does discrimination, bullying and harassment play? Drawing on qualitative interviews with 48 healthcare staff in London (UK), we identify how micro-level bullying, prejudice, discrimination and harassment behaviours, independently and in combination, exploit and maintain meso-level racialised hierarchies. Within teams, the high diversity-low inclusion dynamic shaped and was perpetuated by in- and outgroup inclusion and exclusion processes (including "insidious dismissal") often employing bullying or microaggressions. These were linked to intersecting factors, such as race, ethnicity, migration, language and religion, and could increase segregation. For racially and ethnically minoritised groups, ingroup maintenance, moving teams or leaving were also ways of coping with organisational inequities. We discuss implications for tackling racialised workplace inequities.

"There Is So Much More for Us to Lose If We Were to Kill Ourselves": Understanding Paradoxically Low Rates of Self-Harm in a Socioeconomically Disadvantaged Community in London.

London has unexpectedly low overall rates of self-harm in public health data and contains highly deprived areas with these paradoxically low rates. Qualitative data were collected via interviews and focus groups with 26 individuals living and working in one such area. Using the Stress Process Model, we explore why this ethnically diverse community, which is exposed to multiple, chronic stressors, might nonetheless appear to have low rates of self-harm. Participants described significant impacts of stressors on the mental health of people locally. These were partly buffered by social resources related to community solidarity and a culture of self-reliance. However, identifying oneself as mentally ill through being known to have self-harmed was seen as highly risky, diminishing a person's social status and exposing them to additional stressors from the community and services. Consequently, people tended to hide distress, respond with behaviors less linked to mental illness, and avoid mental health services.

Managing demand for social care among adults with intellectual disabilities: A systematic scoping review.

BACKGROUND: Demand for formal social services support for adults with intellectual disabilities is increasing internationally. Initiatives which empower individuals with intellectual disabilities to improve their health, develop living skills or manage chronic illnesses may promote independence and reduce unnecessary dependency on social services. METHODS: A "preventative framework" to managing demand comprising several domains was developed from existing literature to guide the search strategy. RESULTS: Fourteen papers related to three domains in the predetermined preventative framework were selected for inclusion in the review, including twelve economic studies. Outcomes included measurement of care needs, and cost-comparison between social care models or cost-effectiveness of interventions. Due to the heterogeneity, the present authors were not able to quantitatively synthesize findings. CONCLUSIONS: The present authors conclude that evidence linking initiatives across sectors to demand for adult social care is lacking. The present authors identify several gaps in the literature and make recommendations for future research and data recording in practice.

Correction to: Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study.

Following publication of the original article [1], the authors notified us of an error in the reported percentages in Table 3.

Impact of co-located welfare advice in healthcare settings: prospective quasi-experimental controlled study.

BackgroundEvaluations of primary healthcare co-located welfare advice services have been methodologically limited.AimsTo examine the impact and cost-consequences of co-located benefits and debt advice on mental health and service use.MethodProspective, controlled quasi-experimental study in eight intervention and nine comparator sites across North Thames. Changes in the proportion meeting criteria for common mental disorder (CMD, 12-item General Health Questionnaire); well-being scores (Shortened Warwick and Edinburgh Mental Well-being Scale), 3-month GP consultation rate and financial strain were measured alongside funding costs and financial gains.ResultsRelative to controls, CMD reduced among women (ratio of odds ratios (rOR) = 0.37, 95% CI 0.20-0.70) and Black advice recipients (rOR = 0.09, 95% CI 0.03-0.28). Individuals whose advice resulted in positive outcomes demonstrated improved well-being scores (ß coefficient 1.29, 95% CI 0.25-2.32). Reductions in financial strain (rOR = 0.42, 95% CI 0.23-0.77) but no changes in 3-month consultation rate were found. Per capita, advice recipients received £15 per £1 of funder investment.ConclusionsCo-located welfare advice improves short-term mental health and well-being, reduces financial strain and generates considerable financial returns.

Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study.

BACKGROUND: Breast and cancer screening uptake has been found to be lower among women with serious mental illness (SMI). This study aims to corroborate these findings in the UK and to identify variation in screening uptake by illness/treatment factors, and primary care consultation frequency. METHODS: Linked population-based primary and secondary care data from the London borough of Lambeth (UK) were used to compare breast and cervical screening receipt among linked eligible SMI patients (n = 625 and n = 1393), to those without SMI known only to primary care (n = 106,554 and n = 25,385) using logistic regression models adjusted first for socio-demographic factors and second, additionally for primary care consultation frequency. RESULTS: Eligible SMI patients were less likely to have received breast (adjusted odds ratio (OR) 0.69, 95 % confidence interval (CI), 0.57 - 0.84, p < 0.001) or cervical screening (adjusted OR 0.72, CI: 0.60 - 0.85, p < 0.001). Schizophrenia diagnosis, depot injectable antipsychotic prescription, and illness severity and risk were associated with the lowest odds of uptake of breast (adjusted ORs 0.46 to 0.59, all p < 0.001) and cervical screening (adjusted ORs 0.48 - 0.65, all p < 0.001). Adjustments for consultation frequency further reduced effect sizes for all subgroups of SMI patient, in particular for cervical screening. CONCLUSIONS: Women with SMI are less likely to receive breast and cervical cancer screening than comparable women without SMI. Higher primary care consultation rates among SMI patients is likely a mediating factor between SMI status and uptake, particularly for cervical screening - a service organised in primary care. To tackle health disparities linked to SMI, efforts at increasing screening uptake are key and should be targeted at women with other markers of illness severity or risk, beyond SMI status alone.

Patterns of physical co-/multi-morbidity among patients with serious mental illness: a London borough-based cross-sectional study.

BACKGROUND: Serious mental illness (SMI) is associated with elevated mortality compared to the general population; the majority of this excess is attributable to co-occurring common physical health conditions. There may be variation within the SMI group in the distribution of physical co/multi-morbidity. This study aims to a) compare the pattern of physical co- and multi-morbidity between patients with and without SMI within a South London primary care population; and, b) to explore socio-demographic and health risk factors associated with excess physical morbidity among the SMI group. METHODS: Data were obtained from Lambeth DataNet, a database of electronic patient records derived from general practices in the London borough of Lambeth. The pattern of 12 co-morbid common physical conditions was compared by SMI status. Multivariate ordinal and logistic regression analyses were conducted to assess the strength of association between each condition and SMI status; adjustments were made for potentially confounding socio-demographic characteristics and for potentially mediating health risk factors. RESULTS: While SMI patients were more frequently recorded with all 12 physical conditions than non-SMI patients, the pattern of co-/multi-morbidity was similar between the two groups. Adjustment for socio-demographic characteristics - in particular age and, to a lesser extent ethnicity, considerably reduced effect sizes and accounted for some of the associations, though several conditions remained strongly associated with SMI status. Evidence for mediation by health risk factors, in particular BMI, was supported. CONCLUSIONS: SMI patients are at an elevated risk of a range of physical health conditions than non-SMI patients but they do not appear to experience a different pattern of co-/multimorbidity among those conditions considered. Socio-demographic differences between the two groups account for some of the excess in morbidity and known health risk factors are likely to mediate the association. Further work to examine a wider range of conditions and health risk factors would help determine the extent of excess mortality attributable to these factors.

Co-production of an online research and resource platform for improving the health of young people-The hype project.

Mental health conditions tend to go unrecognised and untreated in adolescence, and therefore it is crucial to improve the health and social outcomes for these individuals through age and culturally appropriate interventions. This paper aims firstly to describe the development and implementation of the HYPE project platform (a research and resource platform co-designed and co-produced with young people). The second aim is to describe the characteristics of participants who engaged with the platform and an embedded pilot online survey. Participatory action research approach was used to address objectives of the HYPE project. Data were analysed to: (1) help improve access to health and social services, (2) guide provision of information of online resources and (3) deliver complementary community-based events/activities to promote mental health and to ultimately prevent mental health issues. Pilot and main phases of the HYPE project demonstrated the capacity and feasibility for such a platform to reach local, national, and international populations. Analyses demonstrated that the platform was particularly relevant for young females with pre-existing health difficulties. Some of the barriers to involving young people in research and help-seeking are discussed.

Intersectionality informed and narrative-shifting whole school approaches for LGBTQ+ secondary school student mental health: A UK qualitative study.

School is a key site for prevention and early intervention in public mental health, with sexual and gender minority students being a priority group for action. Context is important in understanding how school inclusion of sexual and gender minorities shapes mental health and well-being, with rapidly changing social and political forces necessitating ongoing research. This coproduced UK secondary school-based study aimed to understand (a) key components of mentally, socially and emotionally healthy school environments for LGBTQ+ students considerate of intersecting minoritised identities; (b) staff information, skills and capacity needs and (c) factors influencing uptake and implementation. Online interviews and focus groups were conducted with 63 participants (22 staff, 32 students (aged 13-19 years), and 9 training providers), diverse in relation to gender and sexual identity, ethnicity, religious and social context. Data were analysed thematically. One overarching theme captured the need for an intersectionality-informed, contextually adaptable, whole school approach which 'shifts the narrative' away from deficit thinking, challenging prevailing cis/heteronormative and White norms. This underpinned four themes: (1) 'Feeling safe, seen and celebrated: embedding intersectional signs, signals and symbols', (2) 'Everyone's business: the need for collaboration', (3) 'Embedding a culture of change', and (4) 'Re-locating the problem: challenging deficit thinking'. Contextually diverse research is needed which critically addresses ways in which social power enacted interpersonally and structurally serves to hinder schools from enacting LGBTQ+ inclusivity. Evidence to inform and develop implementation strategies for institutional changes and to advocate for wider socio-political support is also key to mitigate the potential for widening inequities linked to inequitable school environments.

Dietary fiber intake and risk of first stroke: a systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Fiber intake is associated with reduced stroke risk in prospective studies, but no meta-analysis has been published to date. METHODS: Multiple electronic databases were searched for healthy participant studies reporting fiber intake and incidence of first hemorrhagic or ischemic stroke, published between January 1990 and May 2012. RESULTS: Eight cohort studies from the United States, northern Europe, Australia, and Japan met inclusion criteria. Total dietary fiber intake was inversely associated with risk of hemorrhagic plus ischemic stroke, with some evidence of heterogeneity between studies (I(2); relative risk per 7 g/day, 0.93; 95% confidence interval, 0.88-0.98; I(2)=59%). Soluble fiber intake, per 4 g/day, was not associated with stroke risk reduction with evidence of low heterogeneity between studies, relative risk 0.94 (95% confidence interval, 0.88-1.01; I(2)=21%). There were few studies reporting stroke risk in relation to insoluble fiber or fiber from cereals, fruit, or vegetables. CONCLUSIONS: Greater dietary fiber intake is significantly associated with lower risk of first stroke. Overall, findings support dietary recommendations to increase intake of total dietary fiber. However, a paucity of data on fiber from different foods precludes conclusions regarding the association between fiber type and stroke. There is a need for future studies to focus on fiber type and to examine risk for ischemic and hemorrhagic strokes separately.

A mixed methods PAR study investigating social capital as a resource for Black and other racially minoritised communities in the UK: A study protocol.

Understanding how different Black and other racially minoritised communities thrive is an emerging priority area in mental health promotion. Literature demonstrates health benefits of social capital (social resources embedded within social networks). However, its effects are not always positive, particularly for certain subpopulations who are already disadvantaged.The CONtributions of social NEtworks to Community Thriving (CONNECT) study will use Participatory Action Research (PAR) to investigate social capital as a resource that benefits (or hinders) racially minoritised communities and their mental health. The CONNECT study was designed within a partnership with community organisations and responds to local policy in two South-East London Boroughs, thereby providing potential channels for the action component of PAR. Taking an anti-racism lens, we acknowledge the underpinning role of racism in creating health inequities. We apply an intersectional framework to be considerate of overlapping forms of oppression such as age, gender, socioeconomic status, and sexual orientation as an essential part of developing effective strategies to tackle health inequities. Key components of this mixed methods PAR study include (1) involving racialised minority community members as peer researchers in the team (2) collecting and analysing primary qualitative data via interviews, photovoice, and community mapping workshops, (3) developing relevant research questions guided by peer researchers and collaborating organisations and analysing secondary quantitative data accordingly, (4) integrating qualitative and quantitative phases, and (5) working closely with community and policy partners to act on our findings and use our research for social change.The PAR approach will allow us to engage community (voluntary sector and government) and academic partners in decision making and help address imbalances in power and resource allocation. Knowledge generated through this collaborative approach will contribute to existing community initiatives, policies, and council strategies. This will ensure the views and experiences of racially minoritised communities drive the changes we are collaboratively committed to achieving.

What are the effects of having an illness or injury whilst deployed on post deployment mental health? A population based record linkage study of UK army personnel who have served in Iraq or Afghanistan.

BACKGROUND: The negative impact of sustaining an injury on a military deployment on subsequent mental health is well-documented, however, the relationship between having an illness on a military operation and subsequent mental health is unknown. METHODS: Population based study, linking routinely collected data of attendances at emergency departments in military hospitals in Iraq and Afghanistan [Operational Emergency Department Attendance Register (OpEDAR)], with data on 3896 UK Army personnel who participated in a military health study between 2007 and 2009 and deployed to Iraq or Afghanistan between 2003 to 2009. RESULTS: In total, 13.8% (531/3896) of participants had an event recorded on OpEDAR during deployment; 2.3% (89/3884) were medically evacuated. As expected, those medically evacuated for an injury were at increased risk of post deployment probable PTSD (odds ratio 4.27, 95% confidence interval 1.80-10.12). Less expected was that being medically evacuated for an illness was also associated with a similarly increased risk of probable PTSD (4.39, 1.60-12.07) and common mental disorders (2.79, 1.41-5.51). There was no association between having an OpEDAR event and alcohol misuse. Having an injury caused by hostile action was associated with increased risk of probable PTSD compared to those with a non-hostile injury (3.88, 1.15 to 13.06). CONCLUSIONS: Personnel sustaining illnesses on deployment are just as, if not more, at risk of having subsequent mental health problems as personnel who have sustained an injury. Monitoring of mental health problems should consider those with illnesses as well as physical injuries.

Health system influences on potentially avoidable hospital admissions by secondary mental health service use: A national ecological study.

OBJECTIVES: Potentially avoidable hospital admissions (PAAs) are costly to health services and potentially harmful for patients. This study aimed to compare area-level PAA rates among people using and not using secondary mental health services in England and to identify health system features that may influence between-area PAA variation. METHODS: National ecological study using linked English hospital admissions and secondary mental health services data (2016-2018). We calculated two-year average age-sex standardised area-level PAA rates according to primary admission diagnoses for 12 physical conditions, among, first, secondary mental health service users with any non-organic diagnosis, and, second, people not in contact with secondary mental health services. We used penalised regression analyses to identify predictors of area-level variation in PAA rates. RESULTS: Area-level PAA rates were over four times greater in the mental health group, at 7,594 per 100,000 population compared to 1,819 per 100,000 in the comparator group. Common predictors of variation were greater density of older age groups (lower PAA rates), higher underlying population morbidity of chronic obstructive pulmonary disease and, to a lesser extent, urbanity (higher PAA rates). For both groups, health system factors such as the number of general practitioners per capita or ambulance despatch rates were significant but weak predictors of variation. Mental health diagnosis data were available for half of secondary mental health care records only and sensitivity analyses found that urbanity remained the sole significant predictor for PAAs in this group. CONCLUSIONS: Findings support the need for improved management of physical conditions for secondary mental health service users. Understanding and predicting variation in PAAs among mental health service users is constrained by availability of data on mental health diagnosis, physical health care and needs.