The role of constraints and information gaps in driving risky medicine purchasing practices in four African countries.

Substandard and falsified (SF) medical products pose a major threat to public health and socioeconomic development, particularly in low- and middle-income countries. In response, public education campaigns have been developed to alert consumers about the risks of SF medicines and provide guidance on 'safer' practices, along with other demand- and supply-side measures. However, little is currently known about the potential effectiveness of such campaigns while structural constraints to accessing quality-assured medicines persist. This paper analyses survey data on medicine purchasing practices, information and constraints from four African countries (Ghana, Nigeria, Sierra Leone and Uganda; n > 1000 per country). Using multivariate regression and structural equation modelling, we present what we believe to be the first attempt to tease apart, statistically, the effects of an information gap vs structural constraints in driving potential public exposure to SF medicines. The analysis confirms that less privileged groups (including, variously, those in rural settlements, with low levels of formal education, not in paid employment, often women and households with a disability or long-term sickness) are disproportionately potentially exposed to SF medicines; these same demographic groups also tend to have lower levels of awareness and experience greater levels of constraint. Despite the constraints, our models suggest that public health education may have an important role to play in modifying some (but not all) risky practices. Appropriately targeted public messaging can thus be a useful part of the toolbox in the fight against SF medicines, but it can only work effectively in combination with wider-reaching reforms to address higher-level vulnerabilities in pharmaceutical supply chains in Africa and expand access to quality-assured public-sector health services.

Investigating health and social outcomes of the Big Local community empowerment initiative in England: a mixed method evaluation.

Background: Most research on community empowerment provides evidence on engaging communities for health promotion purposes rather than attempts to create empowering conditions. This study addresses this gap. Intervention: Big Local started in 2010 with £271M from the National Lottery. Ending in 2026, it gives 150 relatively disadvantaged communities in England control over £1M to improve their neighbourhoods. Objective: To investigate health and social outcomes, at the population level and among engaged residents, of the community engagement approach adopted in a place-based empowerment initiative. Study design, data sources and outcome variables: This study reports on the third wave of a longitudinal mixed-methods evaluation. Work package 1 used a difference-in-differences design to investigate the impact of Big Local on population outcomes in all 150 Big Local areas compared to matched comparator areas using secondary data. The primary outcome was anxiety; secondary outcomes included a population mental health measure and crime in the neighbourhood. Work package 2 assessed active engagement in Big Local using cross-sectional data and nested cohort data from a biannual survey of Big Local partnership members. The primary outcome was mental well-being and the secondary outcome was self-rated health. Work package 3 conducted qualitative research in 14 Big Local neighbourhoods and nationally to understand pathways to impact. Work package 4 undertook a cost-benefit analysis using the life satisfaction approach to value the benefits of Big Local, which used the work package 1 estimate of Big Local impact on life satisfaction. Results: At a population level, the impacts on 'reporting high anxiety' (-0.8 percentage points, 95% confidence interval -2.4 to 0.7) and secondary outcomes were not statistically significant, except burglary (-0.054 change in z-score, 95% confidence interval -0.100 to -0.009). There was some effect on reduced anxiety after 2017. Areas progressing fastest had a statistically significant reduction in population mental health measure (-0.053 change in z-score, 95% confidence interval -0.103 to -0.002). Mixed results were found among engaged residents, including a significant increase in mental well-being in Big Local residents in the nested cohort in 2018, but not by 2020; this is likely to be COVID-19. More highly educated residents, and males, were more likely to report a significant improvement in mental well-being. Qualitative accounts of positive impacts on mental well-being are often related to improved social connectivity and physical/material environments. Qualitative data revealed increasing capabilities for residents' collective control. Some negative impacts were reported, with local factors sometimes undermining residents' ability to exercise collective control. Finally, on the most conservative estimate, the cost-benefit calculations generate a net benefit estimate of £64M. Main limitations: COVID-19 impacted fieldwork and interpretation of survey data. There was a short 4-year follow-up (2016/20), no comparators in work package 2 and a lack of power to look at variations across areas. Conclusions: Our findings suggest the need for investment to support community organisations to emerge from and work with communities. Residents should lead the prioritisation of issues and design of solutions but not necessarily lead action; rather, agencies should work as equal partners with communities to deliver change. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information.

The Communities in Control study is looking at the health impacts of the Big Local community empowerment programme, funded by the National Lottery Community Fund and managed by Local Trust (a national charitable organisation). Residents of 150 English areas have at least £1M and other support to improve the neighbourhoods. There have been three phases of the research. This report shares findings from their third phase, which began in 2018. First, we used data from a national survey and data from national health and welfare services to compare changes in mental health between people living in Big Local areas and those in similar areas that did not have a Big Local partnership. Furthermore, we also used publicly available data on crime in the neighbourhoods. We found weak evidence that Big Local was linked with improved mental health and a reduction in burglaries. Second, we used data from a survey conducted by Local Trust to look at health and social impacts on the most active residents. We found an increase in mental well-being in 2018 but this was not maintained in 2020, probably due to the COVID-19 pandemic. Third, we did interviews and observations in 14 Big Local areas to understand what helps and what does not help residents to improve their neighbourhoods. We found that partnerships need to have legitimacy, the right balance of support, and learning opportunities. Residents suggested that creating social connections and welcoming social spaces, improving how people view the area and tackling poverty contributed to health improvements. Direct involvement in Big Local was both stressful and rewarding. Finally, we did a cost­benefit analysis by putting a monetary value on residents' increase in life satisfaction due to Big Local and comparing it with the costs of Big Local. We found that the benefits exceed the costs by at least £60M, suggesting that Big Local provides good value for money.

Preventing cardiotoxicity in patients with breast cancer and lymphoma: protocol for a multicentre randomised controlled trial (PROACT).

INTRODUCTION: Anthracyclines are included in chemotherapy regimens to treat several different types of cancer and are extremely effective. However, it is recognised that a significant side effect is cardiotoxicity; anthracyclines can cause irreversible damage to cardiac cells and ultimately impaired cardiac function and heart failure, which may only be evident years after exposure. The PROACT trial will establish the effectiveness of the ACE inhibitor enalapril maleate (enalapril) in preventing cardiotoxicity in patients with breast cancer and non-Hodgkin's lymphoma (NHL) receiving anthracycline-based chemotherapy. METHODS AND ANALYSIS: PROACT is a prospective, randomised, open-label, blinded end-point, superiority trial which will recruit adult patients being treated for breast cancer and NHL at NHS hospitals throughout England. The trial aims to recruit 106 participants, who will be randomised to standard care (high-dose anthracycline-based chemotherapy) plus enalapril (intervention) or standard care alone (control). Patients randomised to the intervention arm will receive enalapril (starting at 2.5 mg two times per day and titrating up to a maximum dose of 10 mg two times per day), commencing treatment at least 2 days prior to starting chemotherapy and finishing 3 weeks after their last anthracycline dose. The primary outcome is the presence or absence of cardiac troponin T release at any time during anthracycline treatment, and 1 month after the last dose of anthracycline. Secondary outcomes will focus on cardiac function measured using echocardiogram assessment, adherence to enalapril and side effects. ETHICS AND DISSEMINATION: A favourable opinion was given following research ethics committee review by West Midlands-Edgbaston REC, Ref: 17/WM/0248. Trial findings will be disseminated through engagement with patients, the oncology and cardiology communities, NHS management and commissioning groups and through peer-reviewed publication. TRIAL REGISTRATION NUMBER: NCT03265574.

No new fast-food outlets allowed! Evaluating the effect of planning policy on the local food environment in the North East of England.

The environment in which we live impacts on our health. The food available to us in our environment is likely to influence what we eat and subsequently our weight. The use of planning policy can be one way for both local and national government to help shape a healthy environment. In England there are three main types of planning policy used to promote a healthy food environment: 1) restricting new fast-food outlets near schools; 2) restricting new fast-food outlets if the density of existing outlets has surpassed a certain threshold of all retail outlets, 3) restricting new fast-food outlets if childhood obesity rates are above a certain threshold. In 2015, Gateshead council, a local authority in the North East of England implemented all three types of guidance. We utilise a longitudinal administrative dataset, the Food Standards Agency Food Hygiene Rating Scheme Data, covering the period 2012-2019 on all premises selling or preparing food in Great Britain. To analyse the impact of employing all three types of planning guidance on the density, proportion, and number of fast-food outlets in Gateshead, we employ a propensity score matching difference-in-difference approach. We match small geographical areas in Gateshead (lower super output areas) to other local authorities in the North East with similar demographic characteristics that did not implement planning guidance. Results show a reduction in density of fast-food outlets by 12.45 per 100,000 of the population and a 13.88% decrease in the proportion of fast-food outlets in Gateshead compared to other similar local authorities in the North East. There was a marginally significant reduction in the number of restaurants which became insignificant after controlling for population density. These results suggest that a multi-pronged planning approach significantly changed the proportion and density of fast-food outlets in the food environment in the short term (4 years).

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice.

BACKGROUND: The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve? METHODS: We searched six academic databases for recent (2014-2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis. RESULTS: One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps. CONCLUSION: In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity. TRIAL REGISTRATION: PROSPERO registration number CRD42020177333 .

Early life, life course and gender influences on levels of C-reactive protein among migrant Bangladeshis in the UK.

BACKGROUND AND OBJECTIVES: Humans co-evolved with pathogens, especially helminths, that educate the immune system during development and lower inflammatory responses. The absence of such stimuli in industrialized countries is associated with higher baseline levels of C-reactive protein (CRP) among adults who appear at greater risk for inflammatory disorders. This cross-sectional study examined effects of early life development on salivary CRP levels in 452 British-Bangladeshis who spent varying periods growing up in Bangladesh or UK. We also analyzed how gender and central obesity modulate effects on CRP. We hypothesized that: (i) first-generation Bangladeshis with higher childhood exposure to pathogens would have chronically lower CRP levels than second-generation British-Bangladeshis; (ii) effects would be greater with early childhoods in Bangladesh; (iii) effects by gender would differ; and (iv) increasing obesity would mitigate early life effects. METHODOLOGY: Saliva samples were assayed for CRP using ELISAs, and anthropometric data collected. Participants completed questionnaires about demographic, socioeconomic, lifestyle and health histories. Data were analyzed using multiple linear regression. RESULTS: First-generation migrants who spent early childhoods in mostly rural, unhygienic areas, and moved to UK after age 8, had lower salivary CRP compared to the second-generation. Effects differed by gender, while waist circumference predicted higher CRP levels. CRP increased with years in UK, alongside growing obesity. CONCLUSIONS AND IMPLICATIONS: Our study supports the hypothesis that pathogen exposure in early life lowers inflammatory responses in adults. However, protective effects differed by gender and can be eroded by growing obesity across the life course which elevates risks for other inflammatory disorders. Lay Summary: Migrants to the UK who spent early childhoods in less hygienic environments in Bangladesh that help to educate their immune systems had lower levels of the inflammatory marker, C-reactive protein (CRP) compared to migrants who grew up in UK. Both gender and increasing obesity were associated with increased levels of CRP.

The Gender Pain Gap: gender inequalities in pain across 19 European countries.

AIMS: Chronic pain is increasingly considered to be an international public health issue, yet gender differences in chronic pain in Europe are under-examined. This work aimed to examine gender inequalities in pain across Europe. METHODS: Data for 27,552 men and women aged 25-74 years in 19 European countries were taken from the social determinants of health module of the European Social Survey (2014). Inequalities in reporting pain were measured by means of adjusted rate differences (ARD) and relative adjusted rate risks (ARR). RESULTS: At the pooled pan-European level, a greater proportion of women (62.3%) reported pain than men (55.5%) (ARD 5.5% (95% confidence intervals (CI) 4.1, 6.9), ARR 1.10 (95% CI 1.08, 1.13)). These inequalities were greatest for back/neck pain (ARD 5.8% (95% CI 4.4, 7.1), ARR 1.15 (95% CI 1.12, 1.19)), but were also significant for hand/arm pain (ARD 4.6% (95% CI 3.5, 5.7), ARR 1.24 (95% CI 1.17, 1.30)) and foot/leg pain (ARD 2.6% (95% CI 1.5, 3.8), ARR 1.12 (95% CI 1.07, 1.18)). There was considerable cross-national variation in gender pain inequalities across European countries. CONCLUSIONS: Significant gender pain inequalities exist across Europe whereby women experience more pain than men. The extent of the gender pain gap varies by country. The gender pain gap is a public health concern and should be considered in future prevention and management strategies.

Local Inequalities in Health Behaviours: Longitudinal Findings from the Stockton-On-Tees Cohort Study.

This paper provides a longitudinal examination of local inequalities in health behaviours during a period of austerity, exploring the role of 'place' in explaining these inequalities. Data from the Stockton-on-Tees prospective cohort study of 836 individuals were analysed and followed over 18 months (37% follow-up). Generalised estimating equation models estimated the deprivation gap in health behaviours (smoking status, alcohol use, fruit and vegetable consumption and physical activity practices) between the 20% most- and least-deprived neighborhoods (LSOAs), explored any temporal changes during austerity, and examined the underpinning role of compositional and contextual determinants. All health behaviours, except for frequent physical activity, varied significantly by deprivation (p ≤ 0.001). Smoking was lower in the least-deprived areas (OR 0.21, CI 0.14 to 0.30), while alcohol use (OR 2.75, CI 1.98 to 3.82) and fruit and vegetable consumption (OR 2.55, CI 1.80 to 3.62) were higher in the least-deprived areas. The inequalities were relatively stable throughout the study period. Material factors (such as employment, education and housing tenure) were the most-important and environmental factors the least-important explanatory factors. This study suggests that material factors are the most important 'place' determinants of health behaviours. Health promotion activities should better reflect these drivers.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review.

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)-particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014-2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

The impact of school exclusion zone planning guidance on the number and type of food outlets in an English local authority: A longitudinal analysis.

The use of planning policy to manage and create a healthy food environment has become a popular policy tool for local governments in England. To date there has been no evaluation of their short-term impact on the built environment. We assess if planning guidance restricting new fast food outlets within 400 m of a secondary school, influences the food environment in the local authority of Newcastle Upon Tyne, UK. We have administrative data on all food outlets in Newcastle 3 years pre-intervention 2012-2015, the intervention year 2016, and three years' post-intervention 2016-2019. We employ a difference-in-difference approach comparing postcodes within the school fast food outlet exclusion zone to those outside the fast-food exclusion zones. In the short term (3 years), planning guidance to limit the number of new fast-food outlets in a school exclusion zone did not have a statistically significant impact on the food environment when compared with a control zone.

Micronutrient Adequacy in the Diet of Reproductive-Aged Adolescent Girls and Adult Women in Rural Bangladesh.

Micronutrient deficiencies remain a serious nutritional concern in Bangladesh, especially among rural women of reproductive age (WRA). This study assesses the diet quality of reproductive-aged adolescent girls and adult women (referred to together as WRA in this study), including socio-demographic factors associated with their diet quality. The diet quality of adolescent girls was compared with that of adult women to assess which group was most at risk. The diet quality was measured by calculating the nutrient adequacy ratio (NAR), using the preceding 24 h dietary recall method. The mean adequacy ratio (MAR) was calculated as an overall measure of diet quality using the NAR. Nearly three quarters of WRA (adolescents: 73.1-88.5%; adult women: 72.9-86.4%) had an inadequate intake of calcium, vitamin A, folic acid, and vitamin B12. The prevalence of inadequate dietary intakes of calcium, zinc, and energy was significantly higher in adolescent girls (p < 0.001) than in adult women. Overall diet quality was significantly better in adult women (0.51 ± 0.21, p < 0.001) than in adolescent girls (0.49 ± 0.22). Age, marital status, educational level, and monthly household income were important factors associated with the diet quality of WRA. Micronutrient inadequacy is widely prevalent in the diets of WRA in Bangladesh, and adolescent girls with poor socio-economic status and lower educational levels are at higher risk.

The Northumberland Exercise Referral Scheme as a Universal Community Weight Management Programme: A Mixed Methods Exploration of Outcomes, Expectations and Experiences across a Social Gradient.

Exercise referral schemes (ERS) are internationally recognised, yet little attention has been paid to discrete referral groups or the influence of wider social determinants of health. The primary quantitative element of this mixed methods study used a mixed effects linear model to examine associations of sociodemographic predictors, obesity class and profession of referrer on weight and physical activity (PA) variables for weight-related referrals (n = 3624) to an established 24-week ERS. Chained equations modelling imputed missing data. The embedded qualitative element (n = 7) used individual semi-structured interviews to explore participant weight-related expectations and experiences. Age, gender and profession of referrer influenced weight loss. PA increased and was influenced by age and gender. The weight gap between the most and least obese narrowed over time but the PA gap between most and least widened. Age, employment and obesity class were most predictive of missing data but would unlikely alter overall conclusions. Qualitative themes were weight-loss support, personal circumstances and strategies, and weight expectations versus wellbeing rewards. This ERS worked, did not widen existing obesity inequalities, but demonstrated evidence of PA inequalities for those living with deprivation. To improve equity of experience, we recommend further stakeholder dialogue around referral experience and ongoing support needs.

Assessing the value for money of an integrated health and wellbeing service in the UK.

Lay health workers have been utilized to deliver health promotion programmes in a variety of settings. However, few studies have sought to determine whether these programmes represent value for money, particularly in a UK context. The present study involved an economic evaluation of Wellbeing for Life, an integrated health and wellbeing service in northern England. The service combined one-to-one interventions delivered by lay health workers (known as health trainers), group wellbeing interventions, volunteering opportunities and other community development activities. Value for money was assessed using an established economic model developed with input from a panel of commissioners and providers, and the main data source was the national health trainer data collection and reporting system. Between June 2015 and January 2017, behaviour change outcomes (i.e. whether client goals in relation to diet, physical activity, smoking or other behaviours, had been achieved) were recorded for 2433 of the 3179 individuals who accessed one-to-one interventions. The level of achievement observed gave an estimated total health gain of 287.7 quality-adjusted life years (QALYs). In addition, there were 4669 health-promoting events, five asset mapping projects and 1595 occurrences of signposting to other services. Combining the value of individual behaviour change with the value of these additional activities gave an overall net cost per QALY gained of £3900 and a total estimated societal value of at least £3.45 for every £1 spent on the service. These results suggest that the Wellbeing for Life service offered good value for money. Further research is needed to systematically and comprehensively determine the societal value of similar holistic, asset-based and lay-led approaches.

The European epidemic: Pain prevalence and socioeconomic inequalities in pain across 19 European countries.

BACKGROUND: Using data from the European Social Survey (ESS) 2014, this study presents an update of pain prevalence amongst men and women across Europe and undertakes the first analysis of socioeconomic inequalities in pain. METHODS: Data from the ESS 2014 survey were analysed for three pain variables: back/neck pain (n = 11,032), hand/arm pain (n = 5,954) and foot/leg pain (n = 6,314). Education was used as the indicator of socioeconomic status (SES). Age-adjusted risk differences and age-adjusted risk ratios were calculated from predicted probabilities generated by means of binary logistic regression. These analyses compared the lower education group with the higher education group (the socioeconomic gap), and the medium education group with the higher education group (the gradient). RESULTS: High prevalence rates were reported for all three types of pain across European countries. At a pan-European level, back/neck pain was the most prevalent with 40% of survey participants experiencing pain; then hand/arm pain at 22%, and then foot/leg pain at 21%. There was considerable cross-national variation in pain across European counties, as well as significant socioeconomic inequalities in the prevalence of pain-with social gradients or socioeconomic gaps evident for both men and women; socioeconomic inequalities were most pronounced for hand/arm pain, and least pronounced for back/neck pain. The magnitudes of the socioeconomic pain inequalities differed between countries, but were generally higher for women. CONCLUSIONS: Future strategies to reduce the burden of pain should acknowledge and consider the associated socioeconomic inequalities of pain to ensure the "pain gap" does not widen. SIGNIFICANCE: This is a pan European study that has explored socioeconomic inequalities in pain. Across Europe, pain is more prevalent in people of lower socioeconomic position; these pain inequalities were most significant for hand/arm pain, and least significant for back/neck pain.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low-income and middle-income countries (LMICs): protocol for an umbrella review.

INTRODUCTION: Despite significant progress in the last few decades, infectious diseases remain a significant threat to children's health in low-income and middle-income countries. Effective means of prevention and control for these diseases exist, making any differences in the burden of these diseases between population groups or countries inequitable. Yet, gaps remain in our knowledge of the effect these public health interventions have on health inequalities in children, especially in low-income and middle-income countries. This umbrella review aims to address some of these gaps by exploring which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases among children in low-income and middle-income countries. METHODS AND ANALYSIS: An umbrella review will be conducted to identify systematic reviews or evidence synthesis of public health interventions that reduce morbidity, mortality and/or health inequalities due to infectious diseases among children (aged under 5 years) in low-income and middle-income countries. The interventions of interest are public health interventions targeting infectious diseases or associated risk factors in children. We will search for reviews reporting health and health inequalities outcomes in and between populations. The literature search will be undertaken using the Cochrane Library, Medline, EMBASE, the CAB Global Health database, Health Evidence, the Campbell Collaboration Library of Systematic Reviews, International Initiative for Impact Evaluation Systematic review repository, Scopus, the Social Sciences Citation Index and PROSPERO. Additionally, a manual search will be performed in Google Scholar and three international organisations websites (UNICEF Office of Research-Innocenti, UNICEF, WHO) to capture grey literature. Data from the records meeting our inclusion/exclusion criteria will be collated using a narrative synthesis approach. ETHICS AND DISSEMINATION: This review will exclusively work with anonymous group-level information available from published reviews. No ethical approval was required.The results of the review will be submitted for publication in academic journals and presented at international public health conferences. Additionally, key findings will be summarised for dissemination to a wider policy and general public audience as part of the Centre for Global Health Inequalities Research's policy work. PROSPERO REGISTRATION NUMBER: CRD42019141673.

The Pain Divide: a cross-sectional analysis of chronic pain prevalence, pain intensity and opioid utilisation in England.

OBJECTIVES: Our central research question was, in England, are geographical inequalities in opioid use driven by health need (pain)? To answer this question, our study examined: (1) if there are regional inequalities in rates of chronic pain prevalence, pain intensity and opioid utilisation in England; (2) if opioid use and chronic pain are associated after adjusting for individual-level and area-level confounders. DESIGN: Cross-sectional study design using data from the Health Survey for England 2011. SETTING: England. PRIMARY AND SECONDARY OUTCOME MEASURES: Chronic pain prevalence, pain intensity and opioid utilisation. PARTICIPANTS: Participant data relating to chronic pain prevalence, pain intensity and opioid usage data were obtained at local authority level from the Health Survey for England 2011; in total, 5711 respondents were included in our analysis. METHODS: Regional and local authority data were mapped, and a generalised linear model was then used to explore the relationships between the data. The model was adjusted to account for area-level and individual-level variables. RESULTS: There were geographical variations in chronic pain prevalence, pain intensity and opioid utilisation across the English regions-with evidence of a 'pain divide' between the North and the South, whereby people in the North of England more likely to have 'severely limiting' or 'moderately limiting' chronic pain. The intensity of chronic pain was significantly and positively associated with the use of opioid analgesics. CONCLUSIONS: There are geographical differences in chronic pain prevalence, pain intensity and opioid utilisation across England-with evidence of a 'pain divide'. Given the public health concerns associated with the long-term use of opioid analgesics-and their questionable activity in the management of chronic pain-more guidance is needed to support prescribers in the management of chronic pain, so the initiation of opioids can be avoided.

Missed opportunities: unnecessary medicine use in patients with lung cancer at the end of life - an international cohort study.

AIMS: The aims of the current study were: (i) to examine the prescribing of preventative medication in a cohort of people with advanced lung cancer on hospital admission and discharge across different healthcare systems; and (ii) to explore the factors that influence preventative medication prescribing at hospital discharge. METHODS: A retrospective cohort study was conducted across two centres in the UK and the US. The prescribing of preventative medication was examined at hospital admission and discharge for patients who died of lung cancer. A zero-inflated negative binomial regression model was used to examine the association between preventative medications at discharge and patient- and hospital-based factors. The classes of preventative medication prescribed included were: vitamins and minerals, and antidiabetic, antihypertensive, antihyperlipidaemic and antiplatelet medications. RESULTS: In the UK site (n = 125), the mean number of preventative medications prescribed was 1.9 [standard deviation (SD) 1.7) on admission, and 1.7 (SD 1.7) on discharge, and in the US site (n = 191) the mean was 2.6 (SD 2.2) on admission and 1.9 (SD 2.2) on discharge. The model found a significant association between the number of preventative drugs prescribed on admission and the number on discharge; it also found a significant association between the total number of drugs prescribed on discharge and the number of preventative medications on discharge. Other indicators related to patient and hospital factors were not significantly associated with the number of preventative medications supplied on discharge. CONCLUSIONS: The use of preventative medication was common in lung cancer patients, despite undergoing discharge. Patient- and hospital-based factors did not influence the prescribing of preventative medication.

Change in cost and affordability of a typical and nutritionally adequate diet among socio-economic groups in rural Nepal after the 2008 food price crisis.

Diet quality is an important determinant of nutrition and food security and access can be constrained by changes in food prices and affordability. Poverty, malnutrition, and food insecurity are high in Nepal and may have been aggravated by the 2008 food price crisis. To assess the potential impact of the food price crisis on the affordability of a nutritionally adequate diet in the rural plains of Nepal, data on consumption patterns and local food prices were used to construct typical food baskets, consumed by four different wealth groups in Dhanusha district in 2005 and 2008. A modelled diet designed to meet household requirements for energy and essential nutrients at minimum cost, was also constructed using the 'Cost of Diet' linear programming tool, developed by Save the Children. Between 2005 and 2008, the cost of the four typical food baskets increased by 19% - 26% and the cost of the nutritionally adequate modelled diet increased by 28%. Typical food baskets of all wealth groups were low in macro and micronutrients. Income data for the four wealth groups in 2005 and 2008 were used to assess diet affordability. The nutritionally adequate diet was not affordable for poorer households in both 2005 and 2008. Due to an increase in household income levels, the affordability scenario did not deteriorate further in 2008. Poverty constrained access to nutritionally adequate diets for rural households in Dhanusha, even before the 2008 food price crisis. Despite increased income in 2008, households remain financially unable to meet their nutritional requirements.

Regional inequalities in self-reported conditions and non-communicable diseases in European countries: Findings from the European Social Survey (2014) special module on the social determinants of health.

Background: Within the European Union (EU), substantial efforts are being made to achieve economic and social cohesion, and the reduction of health inequalities between EU regions is integral to this process. This paper is the first to examine how self-reported conditions and non-communicable diseases (NCDs) vary spatially between and within countries. Methods: Using 2014 European Social Survey (ESS) data from 20 countries, this paper examines how regional inequalities in self-reported conditions and NCDs vary for men and women in 174 regions (levels 1 and 2 Nomenclature of Statistical Territorial Units, 'NUTS'). We document absolute and relative inequalities across Europe in the prevalence of eight conditions: general health, overweight/obesity, mental health, heart or circulation problems, high blood pressure, back, neck, muscular or joint pain, diabetes and cancer. Results: There is considerable inequality in self-reported conditions and NCDs between the regions of Europe, with rates highest in the regions of continental Europe, some Scandinavian regions and parts of the UK and lowest around regions bordering the Alps, in Ireland and France. However, for mental health and cancer, rates are highest in regions of Eastern European and lowest in some Nordic regions, Ireland and isolated regions in continental Europe. There are also widespread and consistent absolute and relative regional inequalities in all conditions within countries. These are largest in France, Germany and the UK, and smallest in Denmark, Sweden and Norway. There were higher inequalities amongst women. Conclusion: Using newly available harmonized morbidity data from across Europe, this paper shows that there are considerable regional inequalities within and between European countries in the distribution of self-reported conditions and NCDs.

Are we failing young people not in employment, education or training (NEETs)? A systematic review and meta-analysis of re-engagement interventions.

BACKGROUND: Youth comprise 40% of the world's unemployed, a status associated with adverse wellbeing and social, health, and economic costs. This systematic review and meta-analysis review synthesises the literature on the effectiveness of interventions targeting young people not in employment, education, or training (NEET). METHODS: Randomised and quasi-randomised trials with a concurrent or counterfactual control group and baseline equivalence are included. Cochrane collaboration tools are used to assess quality, and a narrative synthesis was undertaken. The primary outcome is employment; secondary outcomes were health, earnings, welfare receipt, and education. RESULTS: Eighteen trials are included (9 experimental and 9 quasi-experimental), sample sizes range from 32 to 54,923. Interventions include social skills, vocational, or educational classroom-based training, counselling or one-to-one support, internships, placements, on-the-job or occupational training, financial incentives, case management, and individual support. Meta-analysis of three high-quality trials demonstrates a 4% (CI 0.0-0.7) difference between intervention and control groups on employment. Evidence for other outcomes lacks consistency; however, more intensive programmes increase employment and wages over the longer term. CONCLUSIONS: There is some evidence that intensive multi-component interventions effectively decrease unemployment amongst NEETs. The quality of current evidence is limited, leaving policy makers under-served when designing and implementing new programmes, and a vulnerable population neglected. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014007535.