Influenza: cause or excuse? An analysis of flu's influence on worsening mortality trends in England and Wales, 2010-19.

BACKGROUND: England and Wales experienced a stagnation of previously improving life expectancy during the 2010s. Public bodies cited influenza as an important cause. SOURCES OF DATA: We used data from the Office for National Statistics to examine mortality attributed directly to influenza and to all influenza-like diseases for the total population of England and Wales 2010-19. Several combinations of ICD-10 codes were used to address the possibility of under-counting influenza deaths. AREAS OF AGREEMENT: Deaths from influenza and influenza-like diseases declined between 2010 and 2019, while earlier improvements in mortality from all causes of death were stalling and, with some causes, worsening. Our findings support existing research showing that influenza is not an important cause of the stalling of mortality rates 2010-19. AREAS OF CONTROVERSY: Influenza was accepted by many as an important cause of stalling life expectancy for much of the 2010s, while few in public office have accepted austerity as a key factor in the changes seen during that time. GROWING POINTS: This adds to the mounting evidence that austerity damaged health prior to COVID-19 and left the population more vulnerable when it arrived. AREAS FOR DEVELOPING TIMELY RESEARCH: Future research should explore why so many in public office were quick to attribute the change in trends in overall mortality in the UK in this period to influenza, and why many continue to do so through to 2023 and to deny the key role of austerity in harming population health.

When experts disagree: interviews with public health experts on health outcomes in the UK 2010-2020.

OBJECTIVES: To ascertain the views of public health experts on adverse trends in life expectancy across England and Wales over the past decade, causal factors, possible solutions, and their opinions about how the prepandemic situation influenced the UK's COVID-19 response. STUDY DESIGN: Semistructured, in-depth interviews. METHODS: Nineteen public health experts were identified by purposeful sampling and invited to take part via e-mail. Sixty-three percent responded and participated (n = 12), six females and six males. Interviews took place via Microsoft Teams between November 2021 and January 2022. Interviews were transcribed and analysed using thematic content analysis. RESULTS: There was no consensus on the significance of the stalling and, at some ages, reversal of previous improvements in life expectancy between 2010 and 2020. Explanations offered included data misinterpretation, widening health inequalities, and disinvestment in public services, as well as some disease-specific causes. Those accepting that the decline was concerning linked it to social factors and suggested solutions based on increased investment and implementing existing evidence on how to reduce health inequalities. These interviewees also pointed to the same factors playing a role in the UK's poor COVID-19 response, highlighting the need to understand and address these underlying issues as part of pandemic preparedness. CONCLUSIONS: There was no consensus among a group of influential public health experts in the UK on the scale, nature, and explanations of recent trends in life expectancy. A majority called for implementation of existing evidence on reducing inequalities, especially in the wake of COVID-19. However, without agreement on what the problem is, action is likely to remain elusive.

Things Fall Apart: the British Health Crisis 2010-2020.

BACKGROUND: A very large number of studies have reported a stalling of health improvements in the UK since 2010. SOURCES OF DATA: Almost all relevant data are produced by the Office for National Statistics and other national statistical agencies. AREAS OF AGREEMENT: There has been a dramatic slowdown in life expectancy and diverging trends in infant mortality in the UK as a whole and England and Wales, respectively. AREAS OF CONTROVERSY: Many commentators are loath to describe the falls in life expectancy as actual falls or to ascribe blame to the political situation in the UK. GROWING POINTS: Health trends in the UK are worrying and raise important questions about government policies. AREAS TIMELY FOR DEVELOPING RESEARCH: These findings point to a need for greater investment in research on the political determinants of health, on the timely detection and interpretation of evidence of worsening health, and on how political and policy processes respond to such findings.

The impact of the housing crisis on self-reported health in Europe: multilevel longitudinal modelling of 27 EU countries.

BACKGROUND: Many EU nations experienced a significant housing crisis during the Great Recession of 2008-10. We evaluated the consequences of housing payment problems for people's self-reported overall health. METHODS: We used longitudinal data from the EU Statistics on Income and Living Conditions survey covering 27 countries from 2008 to 2010 to follow a baseline sample of persons who did not have housing debt and who were employed (45 457 persons, 136 371 person-years). Multivariate linear regression and multilevel models were used to evaluate the impact of transitions into housing arrears on self-reported health, correcting for the presence of chronic illness, health limitations, and other potential socio-demographic confounders. RESULTS: Persons who transitioned into housing arrears experienced a significant deterioration in self-reported overall health by - 0.03 U (95% CI - 0.01 to - 0.04), even after correcting for chronic illness, disposable income and employment status, and individual fixed effects. This association was independent and similar in magnitude to that for job loss (-0.02, 95% CI: -0.01 to - 0.04). We also found that the impact of housing arrears was significantly worse among renters, corresponding to a mean 0.11 unit additional drop in health as compared with owner-occupiers. These adverse associations were only evident in persons below the 75th percentile of disposable income. DISCUSSION: Our analysis demonstrates that persons who suffer housing arrears experience increased risk of worsening self-reported health, especially among those who rent. Future research is needed to understand the role of alternative housing support systems and available strategies for preventing the health consequences of housing insecurity.

A deathly silence: why has the number of people found decomposed in England and Wales been rising?

OBJECTIVES: The number of deaths occurring in private homes in England and Wales had been rising for years, increasingly rapidly from 2020. Media stories and research linked decomposing bodies found in private homes with pandemic-related social isolation. We aim to explore whether these incidents are one-offs or part of a wider trend. DESIGN: Descriptive analysis of publicly available Office for National Statistics (ONS) data. SETTING: England and Wales. PARTICIPANTS: All residents of England and Wales, 1979 to 2020. MAIN OUTCOME MEASURES: Using data from the Office for National Statistics, we calculate European Age Standardised Rates for deaths coded as R98 ('unattended death') and R99 ('other ill-defined and unknown causes of mortality') in the 10th version of the International Classification of Diseases (ICD-10), and the corresponding codes in ICD-9, by sex and age group from 1979 (when ICD-9 began) to 2020. These are proxy markers for deaths where decomposition precludes attribution of a specific cause at postmortem. RESULTS: While mortality from all other causes decreased from 1979 to 2020, the opposite was seen for deaths from R98 and R99 (or 'undefined deaths'), with men more affected than women. There was a sharp rise in these deaths in both sexes but in men particularly in the 1990s and 2000s, coinciding with a time when overall mortality was rapidly improving. CONCLUSIONS: The increase in people found dead from unknown causes suggests wider societal breakdowns of both formal and informal social support networks. They are concerning and warrant urgent further investigation. We call on national and international authorities to consider measures that would make it possible to identify these deaths more easily in routine data.

Associations between school enjoyment at age 6 and later educational achievement: evidence from a UK cohort study.

Education is influenced by a broad range of factors but there has been limited research into the role that early school enjoyment plays in pupil's educational achievement. Here we used data from a UK cohort to answer three research questions. What is the association between early school enjoyment and later academic achievement? To what extent do family background factors underlie this association? Do sex differences in school enjoyment underlie sex differences in achievement? School enjoyment was self-reported in two questionnaires completed at age 6. We used multiple imputation to account for missing covariates in this study, giving an imputed sample size of 12,135. Children's school enjoyment at age 6 associated with sex and cognitive ability but not family socioeconomic background. For example, girls were twice as likely to report enjoying school than boys (OR: 1.97; 95% CI: 1.56, 2.48). School enjoyment strongly associated with later achievement in age 16 compulsory GCSE exams even after adjustment for socioeconomic background and cognitive ability; pupils who reported enjoying school scored on average 14.4 (95% CI: 6.9, 21.9) more points (equivalent to almost a 3-grade increase across all subjects) and were 29% more likely to obtain 5 + A*-C GCSE's including Maths and English (OR: 1.29; 95% CI: 0.99, 1.7) than those who did not enjoy school. These results highlight the importance of school enjoyment for educational achievement. As a potentially more modifiable factor than socioeconomic background, cognitive ability or sex, school enjoyment may represent a promising intervention target for improving educational outcomes.

Spatial and temporal inequalities in mortality in the USA, 1968-2016.

Previous UK and European research has highlighted important variations in mortality between populations after adjustment for key determinants such as poverty and deprivation. The aim here was to establish whether similar populations could be identified in the US, and to examine changes over time. We employed Poisson regression models to compare county-level mortality with national rates between 1968 and 2016, adjusting for poverty, education, race (a proxy for exposure to racism), population change and deindustrialisation. Results are presented by means of population-weighted cartograms, and highlight widening spatial inequalities in mortality over time, including an urban to rural, and south-westward, shift in areas with the highest levels of such unexplained 'excess' mortality. There is a need to understand the causes of the excess in affected communities, given that it persists after adjustment for such a broad range of important health determinants.

All connected? Geographies of race, death, wealth, votes and births.

In January 2010 we learnt that within London the best-off 10th of the population each had recourse to 273 times the wealth of the worse-off 10th of that population (Hills et al. 2010, An anatomy of economic inequality in the UK Report of the National Equality Panel, Government Equalities Office, London). It is hard to find any city in an affluent country that is more unequal. This wealth gap did not include the assets of the UK super-rich, who mostly live in or near London. In April 2010 the Sunday Times newspaper reported the wealth of the richest 1000 people in the UK had risen by an average of £77 million each in just one year, to now stand at £335.5 billion. Today in the UK we are again as unequal as we were around 1918. For 60 years we became more equal, but for the last 30 years, more unequal. Looking at inequality trends it is very hard, initially, to notice when the party of government changed. However, closer inspection of the time series suggests there were key times when the trends changed direction, when the future was much less like the past and when how people voted and acted appeared to matter more than at other times. With all three main parties offering what may appear to be very similar solutions to the issue of reducing inequality it seems unlikely that voting in 2010 will make much of a difference. However, today inequalities are now at unsustainable extremes. Action has been taken such that some inequalities, especially in education, have begun to shrink. The last two times that the direction of trends in inequalities changed, in the 1920s and 1970s, there were several general elections held within a relatively short time period. Inequality is expensive. The UK is not as well-off as it once was. It could be time for a change again. Which way will we go?

Changes in population movement make COVID-19 spread differently from SARS.

This comment discusses the contribution of population movement to the spread of COVID-19, with a reference to the spread of SARS 17 years ago. We argue that the changing geography of migration, the diversification of jobs taken by migrants, the rapid growth of tourism and business trips, and the longer distance taken by people for family reunion are what make the spread of COVID-19 so differently from that of SARS. These changes in population movement are expected to continue. Hence, new strategies in disease prevention and control should be taken accordingly, which are also proposed in the comment.

The risk of prostate cancer amongst South Asian men in southern England: the PROCESS cohort study.

OBJECTIVE: To reinvestigate whether South Asian men in the UK are at lower risk of being diagnosed with prostate cancer in a UK-based retrospective cohort study and to examine possible reasons that may explain this. PATIENTS AND METHODS: The catchment areas were predefined in four areas of southern England, and age- and race-specific populations for those areas taken from census data. Cases were ascertained through review of multiple hospital sources, while race, other demographic factors, and medical history were determined using questionnaires sent to the men, hospital records review and death certificates. The South Asian group included men of Indian, Bangladeshi and Pakistani origin. RESULTS: There was modest evidence of lower prostate cancer rates in South Asian men compared with their White neighbours (age-adjusted rate ratio 0.81; 95% confidence interval 0.65-1.00). This difference did not reflect less use of prostate-specific antigen (PSA) testing or differences in clinical features at presentation. CONCLUSION: This study provides evidence of a lower incidence of prostate cancer amongst South Asian men living in England, in comparison with their White counterparts. If anything, South Asian men presented with clinical features of earlier disease suggesting that the reduced risk is unlikely to be an artefact of poorer access to health care.

Geographical trends in infant mortality: England and Wales, 1970-2006.

At national level in England and Wales, infant mortality rates fell rapidly from the early 1970s and into the 1980s. Subnational areas have also experienced a reduction in levels of infant mortality. While rates continued to fall to 2006, the rate of reduction has slowed. Although the Government Office Regions Yorkshire and The Humber, the North West and the West Midlands and the Office for National Statistics local authority types Cities and Services and London Cosmopolitan have experienced relatively large absolute reductions in infant mortality, their rates remained high compared with the national average. Within all regions and local authority types, a strong relationship was found between ward level deprivation and infant mortality rates. Nevertheless, levels of infant mortality declined over time even in the most deprived areas with a narrowing of absolute differences in rates between areas. Areas in which the level of deprivation eased have experienced greater than average reductions in levels of infant mortality.

Updating Edwin Chadwick's seminal work on geographical inequalities by occupation.

To honour the 175th anniversary of Edwin Chadwick's seminal 'Report on the Sanitary Conditions of the Labouring Poor', we update Chadwick's famous analysis of geographical differences in occupational based inequalities. Much of the field of Health Geography owes both its direction of development and its initial impetus to his 1842 report. The report presented evidence for the importance of local context to health, with individuals of the lowest occupations in Rutland living longer than individuals of the highest occupations in Liverpool. Here we update the 1842 analysis using data from the Office of National Statistics on individual mortality records by occupation (2010-12) and population data from the 2011 Census. Sex-specific directly standardised premature (16-74) mortality rates were calculated for hierarchical occupational categories similar to Chadwick's categories, for the nearest equivalent areas to those used in Chadwick's report. Although there is no longer consistent evidence on individuals in the lowest occupational group having lower mortality rates than those in the highest group, there were clear social gradients in mortality within each area and the extent of these inequalities varied between areas. Individuals who live in Rutland had lower premature mortality rates across each occupational group compared to the other areas. Our results demonstrate that while life expectancy has nearly doubled since Chadwick's report, social and spatial inequalities in health have persisted. We suggest that Chadwick's legacy on the importance of locality continues.

Why is life expectancy in England and Wales 'stalling'?

Several independent analyses, by both epidemiologists and actuaries, have concluded that the previous rate of improvement of life expectancy in England and Wales has now slowed markedly, and at older ages may even be reversing. However, although these findings have led the pension industry to reduce estimates of future liabilities, they have failed to elicit any significant concern in the Department of Health and Social Care. In this essay, we review the evidence on changing life expectancy, noting that the problems are greatest among older women. We then estimate the gap between what life expectancy is now and what it might have been had previous trends continued. At age 85, the gap is 0.34 years for women and 0.23 for men. We argue that recent changes cannot be dismissed as a temporary aberration. While the causes of this phenomenon are contested, there is growing evidence to point to the austerity policies implemented in recent years as at least a partial explanation. We conclude by calling for a fully independent enquiry to ascertain what is happening to life expectancy in England and Wales and what should be done about it.

Testing the validity of value-added measures of educational progress with genetic data.

Value-added measures of educational progress have been used by education researchers and policy-makers to assess the performance of teachers and schools, contributing to performance-related pay and position in school league tables. They are designed to control for all underlying differences between pupils and should therefore provide unbiased measures of school and teacher influence on pupil progress, however, their effectiveness has been questioned. We exploit genetic data from a UK birth cohort to investigate how successfully value-added measures control for genetic differences between pupils. We use raw value-added, contextual value-added (which additionally controls for background characteristics) and teacher-reported value-added measures built from data at ages 11, 14 and 16. Sample sizes for analyses range from 4,600 to 6,518. Our findings demonstrate that genetic differences between pupils explain little variation in raw value-added measures but explain up to 20% of the variation in contextual value-added measures (95% CI = 6.06% to 35.71%). Value-added measures built from teacher-rated ability have a greater proportion of variance explained by genetic differences between pupils, with 36.3% of their cross-sectional variation being statistically accounted for by genetics (95% CI = 22.8% to 49.8%). By contrast, a far greater proportion of variance is explained by genetic differences for raw test scores at each age of at least 47.3% (95% CI: 35.9 to 58.7). These findings provide evidence that value-added measures of educational progress can be influenced by genetic differences between pupils, and therefore may provide a biased measure of school and teacher performance. We include a glossary of genetic terms for educational researchers interested in the use of genetic data in educational research.

Measuring the impact of major life events upon happiness.

BACKGROUND: In recent years there have been numerous attempts to define and measure happiness in various contexts and pertaining to a wide range of disciplines, ranging from neuroscience and psychology to philosophy, economics and social policy. This article builds on recent work by economists who attempt to estimate happiness regressions using large random samples of individuals in order to calculate monetary 'compensating amounts' for different life 'events'. METHODS: We estimate happiness regressions using the 'major life event' and 'happiness' data from the British Household Panel Survey. RESULTS: The data and methods used in this article suggest that in contrast to living states such as 'being married', it is more events such as 'starting a new relationship' that have the highest positive effect on happiness. This is closely followed by 'employment-related gains' (in contrast to employment status). Also, women who become pregnant on average report higher than average levels of subjective happiness (in contrast to 'being a parent'). Other events that appear to be associated with happiness according to our analysis include 'personal education-related events' (e.g. starting a new course, graduating from University, passing exams) and 'finance/house related events' (e.g. buying a new house). On the other hand, the event that has the highest negative impact upon happiness according to our analysis is 'the end of my relationship' closely followed by 'death of a parent'. Adverse health events pertaining to the parents of the respondents also have a high negative coefficient and so does an employment-related loss. CONCLUSION: The analysis presented in this article suggests that what matters the most in people's lives in Britain is to have good dynamic interpersonal relationships and to be respected at work with that respect being constantly renewed. These 'goods' are as much reflected through dynamic events as static situations. Relationships at work appear to be of a similar order of importance to those at home. Other factors that contribute to higher than average levels of subjective happiness, at least at a superficial level, include delaying death and keeping illness at bay, having babies, buying homes and cars and passing exams. The analysis presented here also suggests that people should not expect too much from their holidays and wider families. The findings presented in this article may help us to understand a little better the propensity for groups to be more or less happy and may help us to begin to better understand the importance of the dynamics of social context-the context in which we come to terms with reward and loss.

Mortality in relation to sex in the affluent world.

BACKGROUND: This paper explores newly available data for 22 countries with reliably recorded mortality data. The past century saw dramatic falls in mortality for both males and females in the most affluent countries of the world. However, these falls are not consistent for both men and women and the inequalities in the male:female mortality ratios are not well understood. DESIGN: By aggregating mortality at each year of life for the 22 countries for those years for which reliable data were recorded (during the period 1850-1999), distinct patterns emerge. RESULTS: In the richer countries of the world, the male:female mortality ratio has been widening for all years of age, particularly for those born from 1942 onwards. Specific cohort effects are clearly identifiable. CONCLUSION: Analysis of the emergent trends suggests that economic activity, status and position possibly provide a better overall explanatory model than a purely biomedical approach.

Is economic adversity always a killer? Disadvantaged areas with relatively low mortality rates.

OBJECTIVES: To identify areas of Britain whose residents have relatively low age specific mortality, despite experiencing long-term economic adversity. METHODS: Longitudinal, ecological study of all residents of Britain from 1971 to 2001. RESULTS: 54 of Britain's 641 parliamentary constituencies were identified as having been persistently economically disadvantaged in the period 1971-2001. Within this group, there was marked variation in age group specific mortality and in the age ranges with relatively high or low mortality. A systematic scoring process identified 18 constituencies as providing strong and consistent evidence of low mortality across a range of age groups, relative to the 54 constituencies as a whole. These 18 were labelled "resilient". Among age groups >24 years, mortality rates in the resilient areas were significantly lower than in the other economically disadvantaged areas. For example, at ages 45-59 years, the average all cause mortality rate in the resilient constituencies was 607 per 100 000 population (95% CI 574 to 641) and 728 (670 to 787) in the non-resilient constituencies (p = 0.013). CONCLUSIONS: Areas with similar adverse economic histories do not all have similarly high mortality rates. It is unlikely that a single factor explains these results. Selective migration cannot be discounted as an explanation, but particular sociocultural features of areas (including the political, economic, ethnic and religious characteristics of their population) may also be protective.