Deaths of despair in England: an observational study of local authority mortality data.

BACKGROUND: Deaths of Despair (DoD) are socially patterned causes of death encompassing drug and alcohol misuse and suicide. DoDs are strongly associated with socioeconomic disadvantage. England has high levels of inequalities, so we hypothesised the existence of marked geographical variations in DoD. We aimed to yield new knowledge on the spatial distribution of DoD, and area-level socioeconomic factors that predict DoD risk in England. METHODS: This observational study was conducted using ICD-10 coded deaths for 307 local authorities in England during 2019-21. Deaths were grouped to non-overlapping categories of drug-related death, alcohol-specific death, and suicide. The mean contributions of each of these causes to the total number of DoD in England were calculated with Poisson exact confidence intervals. Standardised mortality ratios (SMRs) for DoD were generated for each local authority population. A multivariable regression model for DoD risk was developed using 25 socioeconomic variables. FINDINGS: An estimated 46 200 people lost their lives due to DoD between Jan 1, 2019, and Dec 31, 2021. Regional SMRs ranged from 57·4 (SD 16·1) in London to 144·1 (SD 26·8) in the northeast of England (p<0·0001). Alcohol-specific deaths were the largest contributor of DoD, accounting for 44·1% of DoD (95% CI 43·5-44·8), followed by drug-related death (28·1%, 27·7-28·6) and suicide (27·7%, 27·2-28·2). Living in the North, living alone, White British ethnicity, lower inward migration, economic inactivity, income deprivation in older people, employment in elementary occupations, unemployment, and education deprivation in adults were significantly associated with higher DoD rates in England. INTERPRETATION: DoD in England are spatially patterned, with northern regions experiencing a considerably higher burden of mortality from these avoidable causes. A key limitation is ecological bias. This study provides novel insights into area-level risk factors for DoD in England. FUNDING: National Institute for Health and Care Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM).

Evaluating socioeconomic inequalities in influenza vaccine uptake during the COVID-19 pandemic: A cohort study in Greater Manchester, England.

BACKGROUND: There are known socioeconomic inequalities in annual seasonal influenza (flu) vaccine uptake. The Coronavirus Disease 2019 (COVID-19) pandemic was associated with multiple factors that may have affected flu vaccine uptake, including widespread disruption to healthcare services, changes to flu vaccination eligibility and delivery, and increased public awareness and debate about vaccination due to high-profile COVID-19 vaccination campaigns. However, to the best of our knowledge, no existing studies have investigated the consequences for inequalities in flu vaccine uptake, so we aimed to investigate whether socioeconomic inequalities in flu vaccine uptake have widened since the onset of the COVID-19 pandemic. METHODS AND FINDINGS: We used deidentified data from electronic health records for a large city region (Greater Manchester, population 2.8 million), focusing on 3 age groups eligible for National Health Service (NHS) flu vaccination: preschool children (age 2 to 3 years), primary school children (age 4 to 9 years), and older adults (age 65 years plus). The sample population varied between 418,790 (2015/16) and 758,483 (2021/22) across each vaccination season. We estimated age-adjusted neighbourhood-level income deprivation-related inequalities in flu vaccine uptake using Cox proportional hazards models and the slope index of inequality (SII), comparing 7 flu vaccination seasons (2015/16 to 2021/22). Among older adults, the SII (i.e., the gap in uptake between the least and most income-deprived areas) doubled over the 7 seasons from 8.48 (95% CI [7.91,9.04]) percentage points to 16.91 (95% CI [16.46,17.36]) percentage points, with approximately 80% of this increase occurring during the pandemic. Before the pandemic, income-related uptake gaps were wider among children, ranging from 15.59 (95% CI [14.52,16.67]) percentage points to 20.07 (95% CI [18.94,21.20]) percentage points across age groups and vaccination seasons. Among preschool children, the uptake gap increased in 2020/21 to 25.25 (95% CI [24.04,26.45]) percentage points, before decreasing to 20.86 (95% CI [19.65,22.05]) percentage points in 2021/22. Among primary school children, inequalities increased in both pandemic years to reach 30.27 (95% CI [29.58,30.95]) percentage points in 2021/22. Although vaccine uptake increased during the pandemic, disproportionately larger increases in uptake in less deprived areas created wider inequalities in all age groups. The main limitation of our approach is the use of a local dataset, which may limit generalisability to other geographical settings. CONCLUSIONS: The COVID-19 pandemic led to increased inequalities in flu vaccine uptake, likely due to changes in demand for vaccination, new delivery models, and disruptions to healthcare and schooling. It will be important to investigate the causes of these increased inequalities and to examine whether these increased inequalities also occurred in the uptake of other routine vaccinations. These new wider inequalities in flu vaccine uptake may exacerbate inequalities in flu-related morbidity and mortality.

Estimating the heterogeneous health and well-being returns to social participation.

Social participation is defined as an individual's involvement in activities that provide connections with others in society. Past research has demonstrated links between social participation, improved health and well-being, and reduced social isolation, but has been restricted to older people and has not investigated heterogeneity. Using cross-sectional data from the UK's Community Life Survey (2013-2019; N = 50,006), we estimated returns to social participation in the adult population. We included availability of community assets as instruments in a marginal treatment effects model, which allows treatment effects to be heterogeneous and examines whether the effects vary by propensity to participate. Social participation was linked to reduced loneliness and improved health (-0.96 and 0.40 points respectively on 1-5 scales) and increased life satisfaction and happiness (2.17 and 2.03 points respectively on 0-10 scales). These effects were larger for those on low income, with lower education attainment, and who live alone or with no children. We also found negative selection, indicating those less likely to participate have higher health and well-being returns. Future interventions could focus on increasing community asset infrastructure and encouraging social participation for those with lower socio-economic status.

Exploring the health and sociodemographic characteristics of people seeking advice with claiming universal credit: a cross-sectional analysis of UK citizens advice data, 2017-2021.

BACKGROUND: The UK Department for Work and Pensions (DWP) administers Universal Credit (UC) - the main UK benefit for people in- and out-of-work. UC is being rolled out nationally from 2013 to 2024. Citizens Advice (CA) is an independent charity that provides advice and support to people making a claim for UC. The aim of this study is to understand who is seeking advice from CA when making a UC claim and how the types of people seeking advice are changing as the rollout of UC continues. METHODS: Co-developed with Citizens Advice Newcastle and Citizens Advice Northumberland we performed longitudinal analysis of national data from Citizens Advice for England and Wales on the health (mental health and limiting long term conditions) and socio-demographic of 1,003,411 observations for people seeking advice with claiming UC over four financial years (2017/18 to 2020/21). We summarised population characteristics and estimated the differences between the four financial years using population-weighted t-tests. Findings were discussed with three people with lived experience of seeking advice to claim UC to help frame our interpretation and policy recommendations. RESULTS: When comparing 2017/18 to 2018/19, there was a significantly higher proportion of people with limiting long term conditions seeking advice with claiming UC than those without (+ 2.40%, 95%CI: 1.31-3.50%). However, as the rollout continued between 2018/29 and 2019/20 (-6.75%, 95%CI: -9.62%--3.88%) and between 2019/20 and 2020/21 (-2.09%, 95%CI: -2.54%--1.64%), there were significantly higher proportions of those without a limiting long term condition seeking advice than with. When comparing 2018/19 to 2019/20 and 2019/20 to 2020/21, there was a significant increase in the proportion of self-employed compared to unemployed people seeking advice with claiming UC (5.64%, 95%CI: 3.79-7.49%) and (2.26%, 95%CI: 1.29-3.23%) respectively. CONCLUSION: As the rollout for UC continues, it is important to understand how changes in eligibility for UC may impact on those who need help with applying for UC. Ensuring that the advice process and application process is responsive to a range of people with different needs can help to reduce the likelihood that the process of claiming UC will exacerbate health inequalities.

Longitudinal Associations between Peer and Family Relationships, Emotional Symptoms, and Regional Brain Volume across Adolescence.

The period of adolescence brings with it a dynamic interaction between social context and behaviour, structural brain development, and anxiety and depressive symptoms. The rate of volumetric change in the ventromedial prefrontal cortex (vmPFC) and amygdala have been implicated in socioemotional development in adolescence; typically, there is thinning of grey matter volume (GMV) in the vmPFC and growth in the amygdala during this time. The directionality of the associations between social, emotional, and neuroanatomical factors has yet to be untangled, such as the degree to which social variables impact regional brain development, and vice versa. To add, the differences between sexes are still up for debate. In this study, longitudinal associations between peer problems, family support, socioeconomic stress, emotional symptoms, amygdala volume, and vmPFC GMV were investigated for both sexes using latent change score models. Data from a multi-site European study at baseline (mean (SD) age = 14.40 (0.38) years; % female = 53.19) and follow-up 2 (mean (SD) age = 18.90 (0.69) years, % female = 53.19) were used. Results revealed that peer problems did not predict emotional symptoms, rather they changed together over time. For males only, there was positive correlated change between vmPFC GMV, peer problems and emotional symptoms, indicating that slower vmPFC GMV thinning was associated with poorer social and emotional functioning. Additionally, greater family support at age 14 years was associated with slower growth of amygdala volume between ages 14 and 19 years for males; previous research has related slower amygdala growth to resilience to mental health disorders. The findings have extended understanding of mutual social, emotional and brain development, and avenues to protect mental health.

The impact of COVID-19 lockdowns on physical activity amongst older adults: evidence from longitudinal data in the UK.

BACKGROUND: A sedentary lifestyle increases the risk of adverse health outcomes and frailty,particularly for older adults. To reduce transmission during the COVID-19 pandemic, people were instructed to stay at home, group sports were suspended, and gyms were closed, thereby limiting opportunities for physical activity. Whilst evidence suggests that physical activity levels reduced during the pandemic, it is unclear whether the proportion of older adults realising the recommended minimum level of physical activity changed throughout the various stages of lockdown. METHODS: We used a large sample of 3,660 older adults (aged ≥ 65) who took part in the UK Household Longitudinal Study's annual and COVID-19 studies. We examined changes in the proportion of older adults who were realising the UK Chief Medical Officers' physical activity recommendations for health maintenance at several time points before and after COVID-19 lockdowns were imposed. We stratified these trends by the presence of health conditions, age, neighbourhood deprivation, and pre-pandemic activity levels. RESULTS: There was a marked decline in older adults' physical activity levels during the third national lockdown in January 2021. The proportion realising the Chief Medical Officers' physical activity recommendations decreased from 43% in September 2020 to 33% in January 2021. This decrease in physical activity occurred regardless of health condition, age, neighbourhood deprivation, or pre-pandemic activity levels. Those doing the least activity pre-lockdown increased their activity during lockdowns and those doing the most decreased their activity levels. CONCLUSIONS: Reductions in older adults' physical activity levels during COVID-19 lockdowns have put them at risk of becoming deconditioned and developing adverse health outcomes. Resources should be allocated to promote the uptake of physical activity in older adults to reverse the effects of deconditioning.

The healthcare resource impact of maternal mental illness on children and adolescents: UK retrospective cohort study.

BACKGROUND: The general health of children of parents with mental illness is overlooked. AIMS: To quantify the difference in healthcare use of children exposed and unexposed to maternal mental illness (MMI). METHOD: This was a retrospective cohort study of children aged 0-17 years, from 1 April 2007 to 31 July 2017, using a primary care register (Clinical Practice Research Datalink) linked to Hospital Episodes Statistics. MMI included non-affective/affective psychosis and mood, anxiety, addiction, eating and personality disorders. Healthcare use included prescriptions, primary care and secondary care contacts; inflation adjusted costs were applied. The rate and cost was calculated and compared for children exposed and unexposed to MMI using negative binomial regression models. The total annual cost to NHS England of children with MMI was estimated. RESULTS: The study included 489 255 children: 238 106 (48.7%) girls, 112 741 children (23.0%) exposed to MMI. Compared to unexposed children, exposed children had a higher rate of healthcare use (rate ratio 1.27, 95% CI 1.26-1.28), averaging 2.21 extra contacts per exposed child per year (95% CI 2.14-2.29). Increased healthcare use among exposed children occurred in inpatients (rate ratio 1.37, 95% CI 1.32-1.42), emergency care visits (rate ratio 1.34, 95% CI 1.33-1.36), outpatients (rate ratio 1.30, 95% CI 1.28-1.32), prescriptions (rate ratio 1.28, 95% CI 1.26-1.30) and primary care consultations (rate ratio 1.24, 95% CI 1.23-1.25). This costs NHS England an additional £656 million (95% CI £619-£692 million), annually. CONCLUSIONS: Children of mentally ill mothers are a health vulnerable group for whom targeted intervention may create benefit for individuals, families, as well as limited NHS resources.

Does commuting mode choice impact health?

Governments around the world are encouraging people to switch away from sedentary modes of travel towards more active modes, including walking and cycling. The aim of these schemes is to improve population health and to reduce emissions. There is considerable evidence on the latter, but relatively little on the former. This paper investigates the impact of mode choice on physical and mental health. Using data from the UK Household Longitudinal Study, we exploit changes in mode of commute to identify health outcome responses. Individuals who change modes are matched with those whose mode remains constant. Overall we find that mode switches affect both physical and mental health. When switching from car to active travel we see an increase in physical health for women and in mental health for both genders. In contrast, both men and women who switch from active travel to car are shown to experience a significant reduction in their physical health and health satisfaction, and a decline in their mental health when they change from active to public transport.

Corona and coffee on your commute: a spatial analysis of COVID-19 mortality and commuting flows in England in 2020.

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

Prevalence of mental illness in primary care and its association with deprivation and social fragmentation at the small-area level in England.

BACKGROUND: We aimed to spatially describe mental illness prevalence in England at small-area geographical level, as measured by prevalence of depression, severe mental illness (SMI) and antidepressant prescription volume in primary care records, and how much of their variation was explained by deprivation, social fragmentation and sociodemographic characteristics. METHODS: Information on prevalence of depression and SMI was obtained from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/16 and the national dispensing dataset for 2015/16. Linear regression models were fitted to examine ecological associations between deprivation, social fragmentation, other sociodemographic characteristics and mental illness prevalence. RESULTS: Mental illness prevalence varied within and between regions, with clusters of high prevalence identified across England. Our models explained 33.4-68.2% of variability in prevalence, but substantial variability between regions remained after adjusting for covariates. People in socially cohesive and socially deprived areas were more likely to be diagnosed with depression, while people in more socially fragmented and more socially deprived areas were more likely to be diagnosed with SMI. CONCLUSIONS: Our findings suggest that to tackle mental health inequalities, attention needs to be targeted at more socially deprived localities. The role of social fragmentation warrants further investigation, and it is possible that depression remains undiagnosed in more socially fragmented areas. The wealth of routinely collected data can provide robust evidence to aid optimal resource allocation. If comparable data are available in other countries, similar methods could be deployed to identify high prevalence clusters and target funding to areas of greater need.

The effectiveness and cost-effectiveness of strength and balance Exergames to reduce falls risk for people aged 55 years and older in UK assisted living facilities: a multi-centre, cluster randomised controlled trial.

BACKGROUND: Falls are the leading cause of fatal and non-fatal unintentional injuries in older people. The use of Exergames (active, gamified video-based exercises) is a possible innovative, community-based approach. This study aimed to determine the effectiveness of a tailored OTAGO/FaME-based strength and balance Exergame programme for improving balance, maintaining function and reducing falls risk in older people. METHODS: A two-arm cluster randomised controlled trial recruiting adults aged 55 years and older living in 18 assisted living (sheltered housing) facilities (clusters) in the UK. Standard care (physiotherapy advice and leaflet) was compared to a tailored 12-week strength and balance Exergame programme, supported by physiotherapists or trained assistants. Complete case analysis (intention-to-treat) was used to compare the Berg Balance Scale (BBS) at baseline and at 12 weeks. Secondary outcomes included fear of falling, mobility, fall risk, pain, mood, fatigue, cognition, healthcare utilisation and health-related quality of life, and self-reported physical activity and falls. RESULTS: Eighteen clusters were randomised (9 to each arm) with 56 participants allocated to the intervention and 50 to the control (78% female, mean age 78 years). Fourteen participants withdrew over the 12 weeks (both arms), mainly for ill health. There was an adjusted mean improvement in balance (BBS) of 6.2 (95% CI 2.4 to 10.0) and reduced fear of falling (p = 0.007) and pain (p = 0.02) in the Exergame group. Mean attendance at sessions was 69% (mean exercising time of 33 min/week). Twenty-four percent of the control group and 20% of the Exergame group fell over the trial period. The change in fall rates significantly favoured the intervention (incident rate ratio 0.31 (95% CI 0.16 to 0.62, p = 0.001)). The point estimate of the incremental cost-effectiveness ratio (ICER) was £15,209.80 per quality-adjusted life year (QALY). Using 10,000 bootstrap replications, at the lower bound of the NICE threshold of £20,000 per QALY, there was a 61% probability of Exergames being cost-effective, rising to 73% at the upper bound of £30,000 per QALY. CONCLUSIONS: Exergames, as delivered in this trial, improve balance, pain and fear of falling and are a cost-effective fall prevention strategy in assisted living facilities for people aged 55 years or older. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov on 18 Dec 2015 with reference number NCT02634736 .

Association between a national primary care pay-for-performance scheme and suicide rates in England: spatial cohort study.

BACKGROUND: Pay-for-performance policies aim to improve population health by incentivising improvements in quality of care.AimsTo assess the relationship between general practice performance on severe mental illness (SMI) and depression indicators under a national incentivisation scheme and suicide risk in England for the period 2006-2014. METHOD: Longitudinal spatial analysis for 32 844 small-area geographical units (lower super output areas, LSOAs), using population-structure adjusted numbers of suicide as the outcome variable. Negative binomial models were fitted to investigate the relationship between spatially estimated recorded quality of care and suicide risk at the LSOA level. Incidence rate ratios (IRRs) were adjusted for deprivation, social fragmentation, prevalence of depression and SMI as well as other 2011 Census variables. RESULTS: No association was found between practice performance on the mental health indicators and suicide incidence in practice localities (IRR=1.000, 95% CI 0.998-1.002). IRRs indicated elevated suicide risks linked with area-level social fragmentation (1.030; 95% CI 1.027-1.034), deprivation (1.013, 95% CI 1.012-1.014) and rurality (1.059, 95% CI 1.027-1.092). CONCLUSIONS: Primary care has an important role to play in suicide prevention, but we did not observe a link between practices' higher reported quality of care on incentivised mental health activities and lower suicide rates in the local population. It is likely that effective suicide prevention needs a more concerted, multiagency approach. Better training in suicide prevention for general practitioners is also essential. These findings pertain to the UK but have relevance to other countries considering similar programmes.Declaration of interestNone.

A prospective cohort study measuring cost-benefit analysis of the Otago Exercise Programme in community dwelling adults with rheumatoid arthritis.

BACKGROUND: Falls are one of the major health problems in adults with Rheumatoid Arthritis (RA). Interventions, such as the Otago Exercise Programme (OEP), can reduce falls in community dwelling adults by up to 35%. The cost-benefits of such a programme in adults with RA have not been studied. The aims of this study were to determine the healthcare cost of falls in adults with RA, and estimate whether it may be cost efficient to roll out the OEP to improve function and prevent falls in adults living with RA. METHODS: Patients with Rheumatoid Arthritis aged ≥18 years were recruited from four rheumatology clinics across the Northwest of England. Participants were followed up for 1 year with monthly fall calendars, telephone calls and self-report questionnaires. Estimated medical cost of a fall-related injury incurred per-person were calculated and compared with OEP implementation costs to establish potential economic benefits. RESULTS: Five hundred thirty-five patients were recruited and 598 falls were reported by 195 patients. Cumulative medical costs resulting from all injury leading to hospital services is £374,354 (US$540,485). Average estimated cost per fall is £1120 (US$1617). Estimated cost of implementing the OEP for 535 people is £116,479 (US$168,504) or £217.72 (US$314.34) per-person. Based on effectiveness of the OEP it can be estimated that out of the 598 falls, 209 falls would be prevented. This suggests that £234,583 (US$338,116) savings could be made, a net benefit of £118,104 (US$170,623). CONCLUSIONS: Implementation of the OEP programme for patients with RA has potentially significant economic benefits and should be considered for patients with the condition.

The impact of congestion charging on social capital.

We analyse a new data set to examine how congestion charging policies affect an individual's investment social capital. We exploit a (quasi-) natural experiment - the implementation of the Western Extension Zone (WEZ) to the London Congestion Charging zone in 2007. We measure investment in social capital by using the frequency of visits to friends and family before and after the implementation of the WEZ. Using longitudinal data collected in January and November 2007 made available by Transport for London, we perform difference-in-difference analysis, using both OLS and interval regression, with the treatment group defined as those who used a car to make visits pre-WEZ. We observe large and statistically significant reductions in visits as a result of the WEZ, with, for example, a reduction of around 20 visits a year to friends. The effect of the WEZ on the number of visits to act as an informal carer is much larger, with reductions of around 100 visits a year. Given that the changes occurred in such a small time frame (10 months), we conclude that the WEZ is likely to be the main driver of these reductions.

Risk factors for deaths of despair in England: An ecological study of local authority mortality data.

Deaths of Despair (DoD) are socially patterned fatalities encompassing those attributable to drug and alcohol misuse and suicide. DoD occur much more frequently in socially deprived communities. This ecological study aimed to yield new knowledge on the spatial distribution of DoD, and socioeconomic factors that predict DoD risk in England. Via ICD-10 coding, deaths nationally during 2019-2021 were classified to non-overlapping categories of drug-related death, alcohol-specific death, and suicide. The proportion of DoD from each of these causes was calculated and age standardised DoD rates were generated for local authorities. A multivariable regression model for DoD risk was developed using 25 socioeconomic indicators. In 2019-2021, an estimated 46,200 people lost their lives due to DoD. Rates were higher in the North and in coastal areas (p < 0.001), ranging regionally from 25.1/100,000 (SD 6.3) in London to 54.7/100,000 (SD 9.5) in the North East. Alcohol-specific deaths were the largest contributor of DoD, accounting for 44.1% (95%CI 43.5-44.8%) of all such deaths. Living in the North, unemployment, White British ethnicity, living alone, economic inactivity, employment in elementary occupations, and living in urban areas were significantly associated with elevated DoD risk. DoD in England are spatially patterned, with northern regions experiencing a much higher burden of mortality from these avoidable causes. This study provides novel insights into the area-level factors associated with DoD in England. Potential ecological error is a key limitation.

How can healthcare organisations improve the social determinants of health for their local communities? Findings from realist-informed case studies among secondary healthcare organisations in England.

OBJECTIVES: Increasingly, healthcare and public health strategists invite us to look at healthcare organisations as not just care providers but as anchor institutions (ie, large community-rooted organisations with significant impact in the local economy, social fabric and overall community well-being). In response, this study explores the mechanisms through which healthcare organisations can impact social determinants of health and communities in their local areas. DESIGN: We conducted case studies with interviews and synthesised the findings using a realist approach to produce a set of explanations (programme theory) of how healthcare organisations can have a positive impact on the overall well-being of local communities by operating as anchor institutions. SETTING: Secondary healthcare organisations in England, including mental health and community services. PARTICIPANTS: Staff from case study sites which were directly employed or actively engaged in the organisation's anchor institution strategy. Data collection took place from early June to the end of August 2023. RESULTS: We found four building blocks for effective anchor activity including employment, spending, estates and sustainability. Healthcare organisations-as anchor institutions-can improve the social determinants of health for their local communities through enabling accessible paths for local community recruitment and career progression; empowering local businesses to join supply chains boosting income and wealth; transforming organisational spaces into community assets; and supporting local innovation and technology to achieve their sustainability goals. These blocks need to be integrated across organisations on the basis of a population health approach promoted by supportive leadership, and in collaboration with a diverse range of local partners. CONCLUSIONS: Healthcare organisations have the potential for a positive impact on the overall well-being of local communities. Policymakers should support healthcare organisations to leverage employment, spending, estates and sustainability to help address the unequal distribution of the social determinants of health.

Geographic inequalities in need and provision of social prescribing link workers a retrospective study in primary care.

BACKGROUND: Long-term health conditions are major challenges for care systems. Social prescribing link workers have been introduced via primary care networks (PCNs) across England since 2019 to address the wider determinants of health by connecting individuals to activities, groups, or services within their local community. AIM: To assess whether the rollout of social prescribing link workers was in areas with the highest need. DESIGN AND SETTING: A retrospective study of social prescribing link workers in England from 2019 to 2023. METHOD: Workforce, population, survey, and area-level data at the PCN-level from April 2020 to October 2023 were combined. Population need before the rollout of link workers was measured using reported lack of support from local services in the 2019 General Practice Patient Survey. To assess if rollout reflected need, linear regression was used to relate provision of link workers (measured by full-time equivalent [FTE] per 10 000 patients) in each quarter to population need for support. RESULTS: Populations in urban, more deprived areas and with higher proportions of people from minority ethnic groups had the highest reported lack of support. Geographically these were in the North West and London. Initially, there was no association between need and provision; then from July 2022, this became negative and significant. By October 2023, a 10-percentage point higher need for support was associated with a 0.035 (95% confidence interval = -0.634 to -0.066) lower FTE per 10 000 patients. CONCLUSION: Rollout of link workers has not been sufficiently targeted at areas with the highest need. Future deployments should be targeted at those areas.

Gender-related self-reported mental health inequalities in primary care in England: a cross-sectional analysis using the GP Patient Survey.

BACKGROUND: Transgender, non-binary, and gender diverse people face discrimination and barriers to accessing health care. Existing evidence suggests higher rates of mental health conditions among these groups compared with binary and cisgender groups. However, information is limited by poor gender recording in health records and surveys. We aimed to provide the first national estimates of gender-related inequalities in self-reported mental health conditions and mental health support across 15 gender groups in England. METHODS: We used changes to the 2021 and 2022 nationally representative cross-sectional English General Pracitioner (GP) Patient Surveys and used age-adjusted logistic regression to predict probabilities of two outcomes: first, self-reporting a mental health condition and second, self-reporting unmet mental health needs. We report results for 15 exposure groups: five gender groups (female, male, non-binary, prefer to self-describe, and prefer not to say), within three cisgender or transgender identity groups (cisgender, transgender, or prefer not to say). We explored potential mediation by adding covariates. FINDINGS: Of the 1 520 457 respondents in the estimation sample, 861 017 (51·4%) were female, 645 300 (47·4%) were male, 2600 (0·3%) were non-binary, 2277 (0·2%) self-described their gender, and 9263 (0·7%) preferred not to state their gender. 1 499 852 (98·3%) respondents were cisgender, 7994 (0·7%) were transgender, and 12 611 (1·0%) preferred not to say their cisgender or transgender identity. We found wide gender-related inequalities in the probability of self-reporting a mental health condition, with the highest probabilities among non-binary patients who were transgender (47·21% [95% CI 42·86-51·60]) or preferred not to say their cisgender or transgender identity (32·90% [26·50-40·00]), and among transgender patients who self-described their gender (35·03% [27·39-43·53]). With the exception of non-binary patients in each case, probabilities were lowest among cisgender patient groups (ranging from male at 8·80% [8·69-8·92] to female at 11·97% [11·86-12·07]) and patients who preferred not to say their cisgender or transgender identity (ranging from female 7·15% [6·06-8·42] to prefer to self-describe 10·37% [7·13-14·86]). Inequalities in other health conditions and socioeconomic factors might mediate some of these inequalities. Probabilities of self-reported unmet mental health needs were lowest among cisgender male (15·55% [15·33-15·76]) and female (15·93% [15·76-16·10]) patients with increased probabilities among all other groups, ranging from 19·95% (17·57-22·57) in transgender male patients to 28·64% (26·23-31·17) among patients who preferred not to say their gender or their cisgender or transgender identity. Inequalities in interactions with health-care professionals may mediate much of these inequalities. INTERPRETATION: Together with existing evidence, our findings showed large gender-related inequalities in self-reported mental health outcomes in England. Given the existence of self-reported unmet mental health needs, we suggest that better health care system inclusivity and health-care professional training are needed, alongside broader improvements in the social and legal environment for transgender, non-binary, and gender diverse people. FUNDING: National Institute for Health and Care Research.

Risk of Falls and Fractures in Individuals With Cataract, Age-Related Macular Degeneration, or Glaucoma.

Importance: Three leading disease causes of age-related visual loss are cataract, age-related macular degeneration (AMD), and glaucoma. Although all 3 eye diseases have been implicated with falls and fracture risk, evidence is mixed, with the contribution of different eye diseases being uncertain. Objective: To examine whether people with cataract, AMD, or glaucoma have higher risks of falls or fractures than those without. Design, Setting, and Participants: This cohort study was a population-based study in England using routinely collected electronic health records from the Clinical Practice Research Datalink (CPRD) GOLD and Aurum primary care databases with linked hospitalization and mortality records from 2007 to 2020. Participants were people with cataract, AMD, or glaucoma matched to comparators (1:5) by age, sex, and general practice. Data were analyzed from May 2021 to June 2023. Exposures: For each eye disease, we estimated the risk of falls or fractures using separate multivariable Cox proportional hazards regression models. Main Outcomes: Two primary outcomes were incident falls and incident fractures derived from general practice, hospital, and mortality records. Secondary outcomes were incident fractures of specific body sites. Results: A total of 410 476 people with cataract, 75 622 with AMD, and 90 177 with glaucoma were matched (1:5) to 2 034 194 (no cataract), 375 548 (no AMD), and 448 179 (no glaucoma) comparators. The mean (SD) age was 73.8 (11.0) years, 79.4 (9.4) years, and 69.8 (13.1) years for participants with cataract, AMD, or glaucoma, respectively. Compared with comparators, there was an increased risk of falls in those with cataract (adjusted hazard ratio [HR], 1.36; 95% CI, 1.35-1.38), AMD (HR, 1.25; 95% CI, 1.23-1.27), and glaucoma (HR, 1.38; 95% CI, 1.35-1.41). Likewise for fractures, there were increased risks in all eye diseases, with an HR of 1.28 (95% CI, 1.27-1.30) in the cataract cohort, an HR of 1.18 (95% CI, 1.15-1.21) for AMD, and an HR of 1.31 (95% CI, 1.27-1.35) for glaucoma. Site-specific fracture analyses revealed increases in almost all body sites (including hip, spine, forearm, skull or facial bones, pelvis, ribs or sternum, and lower leg fractures) compared with matched comparators. Conclusions and Relevance: The results of this study support recognition that people with 1 or more of these eye diseases are at increased risk of both falls and fractures. They may benefit from improved advice, access, and referrals to falls prevention services.

Impact of Parental Mental Health and Poverty on the Health of the Next Generation: A Multi-Trajectory Analysis Using the UK Millennium Cohort Study.

PURPOSE: Exposure to parental mental ill-health and poverty in childhood impact health across the lifecourse. Both maternal and paternal mental health may be important influences, but few studies have unpicked the complex interrelationships between these exposures and family poverty for later health. METHODS: We used longitudinal data on 10,500 children from the nationally representative UK millennium cohort study. Trajectories of poverty, maternal mental health, and secondary caregiver mental health were constructed from child age of 9 months through to 14 years. We assessed the associations of these trajectories with mental health outcomes at the age of 17 years. Population-attributable fractions were calculated to quantify the contribution of caregivers' mental health problems and poverty to adverse outcomes at the country level. RESULTS: We identified five distinct trajectories. Compared with children with low poverty and good parental mental health, those who experienced poverty and poor primary or secondary caregiver mental health (53%) had worse outcomes. Children exposed to both persistent poverty and poor caregiver mental health were at markedly increased risk of socioemotional behavioural problems (aOR 4.2; 95% CI 2.7-6.7), mental health problems (aOR 2.5; CI 1.6-3.9), and cognitive disability (aOR 1.7; CI 1.1-2.5). We estimate that 40% of socioemotional behavioural problems at the age of 17 were attributable to persistent parental caregivers' mental health problems and poverty. DISCUSSION: More than half of children growing up in the UK are persistently exposed to either one or both of poor caregiver mental health and family poverty. The combination of these exposures is strongly associated with adverse health outcomes in the next generation.