Ethnic Density and Mental Health: Does it Matter Whether the Ethnic Density is Co-ethnic or Multi-ethnic and How Important is Change in Ethnic Density?

The ethnic density thesis suggests a protective health benefit for ethnic minorities living in places with higher concentration of co-ethnic residents. This paper aims to make a step change in the examination of this thesis by proposing ethnic diversity rather than co-ethnic density will be more protective for mental health. The paper proposes ethnic diversity could be a community asset that benefits the health of all people in a neighbourhood regardless of their own ethnic group. Individual data is taken from the UK Household Longitudinal Study, 2009-2019 linked to aggregate data from the 2001 and 2011 Censuses to test the association between co-ethnic density, ethnic diversity and mental health using the General Health Questionnaire 12-item scale. The paper takes a novel approach by measuring pre-existing (in 2001) and change in (2001-2011) co-ethnic density and ethnic diversity. Moderating effects of individual ethnic group, neighbourhood deprivation and perceived social cohesion are tested. Results show lower pre-existing co-ethnic density is related to lower mental health amongst the White British ethnic group but not in most ethnic minority groups. Greater pre-existing ethnic diversity in more deprived neighbourhoods is associated with better mental health regardless of individual ethnic group. A point of contention in the findings is no association between change in ethnic diversity and mental health.

Residence in coastal communities in adolescence and health in young adulthood: An 11-year follow-up of English UKHLS youth questionnaire respondents.

We used the UK Household Longitudinal Study to examine whether community type (inland or coastal) in adolescence (10-15 years) was associated with five adult health outcomes assessed over 11 waves of follow-up (2009-22). When the analyses were stratified on area deprivation, four of the five health outcomes - self-rated, long-standing illness, psychological distress and mental functioning - showed worse health in increasingly more deprived communities, and to a greater extent in the most deprived communities that are coastal. For all but self-rated health, associations were robust to additional adjustment for adolescent gender, ethnicity, household income, tenure, and life satisfaction.

An investigation of the longitudinal relationship between neighbourhood income inequality and individual self-rated health in England.

There are mixed findings on whether neighbourhood income inequality leads to better self-rated health (SRH) or not. This study considers two hypotheses: individuals living in more unequal neighbourhoods have better SRH and the level of neighbourhood income inequality and its impact on SRH is moderated by household and neighbourhood level income related variables. Data from Waves 8-10 of the UK Household Longitudinal Study for respondents living in England at wave 8 were used. Neighbourhood income inequality was measured using Gini coefficients of household income from the Pay As You Earn and benefits systems for Lower Super Output Areas. Longitudinal ordinal multilevel models predicted self-rated health in 2016-18, 2017-19 and 2019-20 by income inequality and its interaction with household income, neighbourhood median income and neighbourhood deprivation, conditional on individual educational attainment, age, sex, ethnic group, years lived in current residence, region of residence and study wave. There were 24,889 respondents analysed over three waves. SRH was worse for those living in more income equal neighbourhoods. There was no indication that neighbourhood inequality was moderated by household income, neighbourhood median income or neighbourhood deprivation. These findings are in line with the balance of existing evidence and support policy interventions that aim to create mixed communities for the purpose of improving population health.

Life course socioeconomic position and general and oral health in later life: Assessing the role of social causation and health selection pathways.

OBJECTIVE: To examine the pathways between life course socioeconomic position (SEP) and general and oral health, assessing the role of two competing theories, social causation and health selection, on a representative sample of individuals aged 50 years and over in England. METHODS: Secondary analysis from the English Longitudinal Study of Ageing Wave 3 data (n = 8659). Structural equation models estimated the social causation pathways from childhood SEP to adult self-rated general health and total tooth loss, and the health selection pathways from childhood health to adult SEP. RESULTS: There were direct and indirect (primarily via education, but also adult SEP, and behavior) pathways from childhood SEP to both health outcomes in older adulthood. There was a direct pathway from childhood health to adult SEP, but no indirect pathway via education. The social causation path total effect estimate was three times larger for self-rated general health and four times larger for total tooth loss than the health selection path respective estimates. CONCLUSIONS: The relationship between SEP and health is bidirectional, but with a clearly stronger role for the social causation pathway.

Life Course Neighbourhood Deprivation and Self-Rated Health: Does It Matter Where You Lived in Adolescence and Do Neighbourhood Effects Build Up over Life?

There is an overreliance on concurrent neighbourhood deprivation as a determinant of health. Only a small section of the literature focuses on the cumulative exposure of neighbourhood deprivation over the life course. This paper uses data from the 1958 National Child Development Study, a British birth cohort study, linked to 1971-2011 Census data at the neighbourhood level to longitudinally model self-rated health between ages 23 and 55 by Townsend deprivation score between ages 16 and 55. Change in self-rated health is analysed using ordinal multilevel models to test the strength of association with neighbourhood deprivation at age 16, concurrently and cumulatively. The results show that greater neighbourhood deprivation at age 16 predicts worsening self-rated health between ages 33 and 50. The association with concurrent neighbourhood deprivation is shown to be stronger compared with the measurement at age 16 when both are adjusted in the model. The concurrent association with change in self-rated health is explained by cumulative neighbourhood deprivation. These findings suggest that neglecting exposure to neighbourhood deprivation over the life course will underestimate the neighbourhood effect. They also have potential implications for public policy suggesting that neighbourhood socioeconomic equality may bring about better population health.

Life Course Neighborhood Deprivation Effects on Body Mass Index: Quantifying the Importance of Selective Migration.

Neighborhood effects research is plagued by the inability to circumvent selection effects -the process of people sorting into neighborhoods. Data from two British Birth Cohorts, 1958 (ages 16, 23, 33, 42, 55) and 1970 (ages 16, 24, 34, 42), and structural equation modelling, were used to investigate life course relationships between body mass index (BMI) and area deprivation (addresses at each age linked to the closest census 1971-2011 Townsend score [TOWN], re-calculated to reflect consistent 2011 lower super output area boundaries). Initially, models were examined for: (1) area deprivation only, (2) health selection only and (3) both. In the best-fitting model, all relationships were then tested for effect modification by residential mobility by inclusion of interaction terms. For both cohorts, both BMI and area deprivation strongly tracked across the life course. Health selection, or higher BMI associated with higher area deprivation at the next study wave, was apparent at three intervals: 1958 cohort, BMI at age 23 y and TOWN at age 33 y and BMI at age 33 y and TOWN at age 42 y; 1970 cohort, BMI at age 34 y and TOWN at age 42 y, while paths between area deprivation and BMI at the next interval were seen in both cohorts, over all intervals, except for the association between TOWN at age 23 y and BMI at age 33 y in the 1958 cohort. None of the associations varied by moving status. In conclusion, for BMI, selective migration does not appear to account for associations between area deprivation and BMI across the life course.

Heterogeneity in the association between youth unemployment and mental health later in life: a quantile regression analysis of longitudinal data from English schoolchildren.

OBJECTIVES: An association between youth unemployment and poorer mental health later in life has been found in several countries. Little is known about whether this association is consistent across individuals or differs in strength. We adopt a quantile regression approach to explore heterogeneity in the association between youth unemployment and later mental health along the mental health distribution. DESIGN: Prospective longitudinal cohort of secondary schoolchildren in England followed from age 13/14 in 2004 to age 25 in 2015. SETTING: England, UK. PARTICIPANTS: 7707 participants interviewed at age 25.Primary and secondary outcome measures12-Item General Health Questionnaire (GHQ) Likert score, a measure of minor psychiatric morbidity. RESULTS: Youth unemployment was related to worse mental health at age 25. The association was several times stronger at deciles of GHQ representing the poorest levels of mental health. This association was only partly attenuated when adjusting for confounding variables and for current employment status. In fully adjusted models not including current employment status, marginal effects at the 50th percentile were 0.73 (95% CI -0.05 to 1.54, b=0.11) points, while marginal effects at the 90th percentile were 3.76 (95% CI 1.82 to 5.83; b=0.58) points. The results were robust to different combinations of control variables. CONCLUSIONS: There is heterogeneity in the longitudinal association between youth unemployment and mental health, with associations more pronounced at higher levels of psychological ill health. Youth unemployment may signal clinically relevant future psychological problems among some individuals.

How robust is the association between youth unemployment and later mental health? An analysis of longitudinal data from English schoolchildren.

BACKGROUND: Several studies show that youth unemployment is associated with worse mental health later in life. However, existing studies report results for only one model, or a few models, and use regression adjustment to support causal claims. We use two novel methods to address these gaps in the literature. METHODS: We use data from Next Steps, a cohort study of English schoolchildren who entered the labour market in the aftermath of the 2008-2009 global financial crisis, and measure mental health using the 12-item General Health Questionnaire (GHQ-12) at age 25. We use specification curve analysis and a negative control outcome design (a form of placebo test) to test whether associations between youth unemployment and later GHQ-12 scores are sensitive to model specification or are likely to be confounded by unobserved factors. RESULTS: We find that the association between unemployment and later GHQ-12 is qualitatively similar across 99.96% of the 120 000 models we run. Statistically significant associations with two placebo outcomes, height and patience, are not present when regression adjustments are made. CONCLUSIONS: There is clear evidence that youth unemployment is related to later mental health, and some evidence that this cannot be easily explained by unobserved confounding.

Fruit and Vegetable Consumption and Incident Prefrailty and Frailty in Community-Dwelling Older People: The English Longitudinal Study of Ageing.

BACKGROUND: There is limited evidence in the literature regarding associations between fruit and vegetable consumption and risk of frailty. OBJECTIVE: To examine associations between fruit and vegetable consumption and risk of incident frailty and incident prefrailty/frailty. DESIGN: A prospective panel study. SETTING AND SUBJECTS: 2634 non-frail community-dwelling men and women aged 60 years or older from the English Longitudinal Study of Ageing (ELSA). METHODS: Fruit and vegetable consumption/day was measured using a self-completion questionnaire at baseline. Frailty status was measured at baseline and follow-up was based on modified frailty phenotype criteria. Four-year incident frailty was examined among 2634 robust or prefrail participants, and incident prefrailty/frailty was measured among 1577 robust participants. RESULTS: Multivariable logistic regression models adjusted for age, gender, and other confounders showed that fruit and vegetable consumption was not associated with incident frailty risks among robust or prefrail participants. However, robust participants consuming 5-7.5 portions of 80 g per day (odds ratio (OR) = 0.56, 95% confidence interval (CI) = 0.37-0.85, p < 0.01) and 7.5-10 portions per day (OR = 0.46, 95%CI = 0.27-0.77, p < 0.01) had significantly lower risk of incident prefrailty/frailty compared with those consuming 0-2.5 portions/day, whereas those consuming 10 or more portions/day did not (OR = 1.10, 95%CI = 0.54-2.26, p = 0.79). Analysis repeated with fruit and vegetable separately showed overall similar results. CONCLUSIONS: Robust older adults without frailty who eat current U.K. government recommendations for fruit and vegetable consumption (5-10 portions/day) had significantly reduced risks of incident prefrailty/frailty compared with those who only eat small amount (0-2.5 portions/day). Older people can be advised that eating sufficient amounts of fruit and vegetable may be beneficial for frailty prevention.

Comparison of Health Outcomes Among High- and Low-Income Adults Aged 55 to 64 Years in the US vs England.

Importance: Socioeconomic differences in life expectancy, health, and disability have been found in European countries as well as in the US. Identifying the extent and pattern of health disparities, both within and across the US and England, may be important for informing public health and public policy aimed at reducing these disparities. Objective: To compare the health of US adults aged 55 to 64 years with the health of their peers in England across the high and low ranges of income in each country. Design, Setting, and Participants: Using data from the Health and Retirement Study (HRS) and the English Longitudinal Study of Ageing (ELSA) for 2008-2016, a pooled cross-sectional analysis of comparably measured health outcomes, with adjustment for demographic characteristics and socioeconomic status, was conducted. The analysis sample included community-dwelling adults aged 55 to 64 years from the HRS and ELSA, resulting in 46 887 person-years of observations. Data analysis was conducted from September 17, 2019, to May 12, 2020. Exposures: Residence in the US or England and yearly income. Main Outcomes and Measures: Sixteen health outcomes were compared, including 5 self-assessed outcomes, 3 directly measured outcomes, and 8 self-reported physician-diagnosed health conditions. Results: This cross-sectional study included 12 879 individuals and 31 928 person-years from HRS (mean [SD] age, 59.2 [2.8] years; 51.9% women) and 5693 individuals and 14 959 person-years from ELSA (mean [SD] age, 59.3 [2.9] years; 51.0% women). After adjusting for individual-level demographic characteristics and socioeconomic status, a substantial health gap between lower-income and higher-income adults was found in both countries, but the health gap between the bottom 20% and the top 20% of the income distribution was significantly greater in the US than England on 13 of 16 measures. The adjusted US-England difference in the prevalence gap between the bottom 20% and the top 20% ranged from 3.6 percentage points (95% CI, 2.0-5.2 percentage points) in stroke to 9.7 percentage points (95% CI, 5.4-13.9 percentage points) for functional limitation. Among individuals in the lowest income group in each country, those in the US group vs the England group had significantly worse outcomes on many health measures (10 of 16 outcomes in the bottom income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the bottom income decile ranged from 7.6% (95% CI, 6.0%-9.3%) vs 3.8% (95% CI, 2.6%-4.9%) for stroke to 75.7% (95% CI, 72.7%-78.8%) vs 59.5% (95% CI, 56.3%-62.7%) for functional limitation. Among individuals in the highest income group, those in the US group vs England group had worse outcomes on fewer health measures (4 of 16 outcomes in the top income decile); the significant differences in adjusted prevalence of health problems in the US vs England for the top income decile ranged from 36.9% (95% CI, 33.4%-40.4%) vs 30.0% (95% CI, 27.2%-32.7%) for hypertension to 35.4% (95% CI, 32.0%-38.7%) vs 22.5% (95% CI, 19.9%-25.1%) for arthritis. Conclusions and Relevance: For most health outcomes examined in this cross-sectional study, the health gap between adults with low vs high income appeared to be larger in the US than in England, and the health disadvantages in the US compared with England are apparently more pronounced among individuals with low income. Public policy and public health interventions aimed at improving the health of adults with lower income should be a priority in the US.

Exploring the Relationship Between Internet Use and Mental Health Among Older Adults in England: Longitudinal Observational Study.

BACKGROUND: There is uncertainty about the impact of internet use on mental health in older adults. Moreover, there is very little known specifically about the impact of particular purposes of internet use. OBJECTIVE: This study aims to investigate the longitudinal relationship between two distinct concepts of mental health with the frequency of internet use among older adults: the moderating role of socioeconomic position (SEP) and the association between specific purposes of internet use. METHODS: Longitudinal fixed and random effects (27,507 person-years) models were fitted using waves 6-8 of the English Longitudinal Study of Ageing to examine the relationship between different aspects of internet use (frequency and purpose) and two mental health outcomes (depression and life satisfaction). The potential moderating effect of SEP on these associations was tested using interaction terms. RESULTS: Infrequent internet use (monthly or less vs daily) was predictive of deteriorating life satisfaction (ß=-0.512; P=.02) but not depression. Education and occupational class had a moderating effect on the association between frequency of internet use and mental health. The associations were stronger in the highest educational group in both depression (P=.09) and life satisfaction (P=.02), and in the highest occupational group in life satisfaction (P=.05) only. Using the internet for communication was associated with lower depression (ß=-0.24; P=.002) and better life satisfaction (ß=.97; P<.001), whereas those using the internet for information access had worse life satisfaction (ß=-0.86; P<.001) compared with those who did not. CONCLUSIONS: Policies to improve mental health in older adults should encourage internet use, especially as a tool to aid communication.

Living longer but not necessarily healthier: The joint progress of health and mortality in the working-age population of England.

Despite improvements in life expectancy, there is uncertainty on whether the increase in years of healthy life expectancy has kept pace. In this paper we explore whether there is empirical support for the expansion of morbidity hypothesis in the population aged 25-64 living in England. Nationally representative cohorts born between 1945 and 1980 are constructed from repeated annual cross-sections of the Health Survey for England, 1991-2014. Later-born cohorts at a given age have the same or higher prevalence of self-reported bad general health and long-term illness, self-reported high blood pressure (in men), self-reported and objectively-measured diabetes, circulatory illnesses, clinical hypertension, and overweight BMI. We also find that healthy life expectancies (in the sense of absence of each of these problems) at age 25 have increased at a slower pace than life expectancy between 1993 and 2013. Our findings lend support to the expansion of morbidity hypothesis and point to increased future demand for specific healthcare services at younger ages.

Are self-reported health inequalities widening by income? An analysis of British pseudo birth cohorts born, 1920-1970.

INTRODUCTION: The health of the British population has been shown to be worsening by self-reported health and improving by self-reported limiting illness for those born before and after 1945. Little is known about the inequality in health difference across British birth cohorts by income. METHODS: Repeated cross-sections from the British General Household Survey, 1979-2011, are used to create pseudo birth cohorts born, 1920-1970, and their gender stratified, age-adjusted limiting illness and self-rated health (SRH) are estimated by household income tertiles. Absolute and relative differences between the poorest and richest income groups are reported. RESULTS: Absolute inequalities in limiting illness between the richest and poorest households have doubled in women and increased by one and a half times in men for those born in 1920-1922 compared with those born in 1968-1970. Relative inequalities in limiting illness increased by a half in women and doubled in men. Absolute inequalities in SRH between the richest and poorest households increased by almost half in women and more than half in men and relative inequalities increased by 18% in women and 14% in men for those born in 1920-1922 compared with those born in 1968-1970. CONCLUSION: Inequalities in self-reported health at the same age by household income have widened for successively later-born British cohorts.

The impact of life course exposures to neighbourhood deprivation on health and well-being: a review of the long-term neighbourhood effects literature.

BACKGROUND: In this review article, we detail a small but growing literature in the field of health geography that uses longitudinal data to determine a life course component to the neighbourhood effects thesis. For too long, there has been reliance on cross-sectional data to test the hypothesis that where you live has an effect on your health and well-being over and above your individual circumstances. METHODS: We identified 53 articles that demonstrate how neighbourhood deprivation measured at least 15 years prior affects health and well-being later in life using the databases Scopus and Web of Science. RESULTS: We find a bias towards US studies, the most common being the Panel Study of Income Dynamics. Definition of neighbourhood and operationalization of neighbourhood deprivation across most of the included articles relied on data availability rather than a priori hypothesis. CONCLUSIONS: To further progress neighbourhood effects research, we suggest that more data linkage to longitudinal datasets is required beyond the narrow list identified in this review. The limited literature published to date suggests an accumulation of exposure to neighbourhood deprivation over the life course is damaging to later life health, which indicates improving neighbourhoods as early in life as possible would have the greatest public health improvement.

Testing Comparability Between Retrospective Life History Data and Prospective Birth Cohort Study Data.

OBJECTIVES: To determine whether comparable prospective and retrospective data present the same association between childhood and life course exposures and mid-life wellbeing. METHOD: Prospective data is taken from the 1958 UK National Child Development Study at age 50 in 2008 and earlier sweeps (n = 8,033). Retrospective data is taken from the English Longitudinal Study of Ageing at ages 50-55 from a life history interview in 2007 (n = 921). RESULTS: There is a high degree of similarity in the direction of association between childhood exposures that have been prospectively collected in National Child Development Study and retrospectively collected in English Longitudinal Study of Ageing and wellbeing outcomes in mid-life. However, the magnitude of these associations is attenuated substantially by the inclusion of measurements, which are difficult or impossible to capture retrospectively, and are only available in prospective data, such as childhood poverty, cognitive ability, and indices of social and emotional adjustment. DISCUSSION: The findings on the one hand provide some reassurance to the growing literature using life history data to determine life course associations with later life wellbeing. On the other hand, the findings show an overestimation in the retrospective data, in part, arising from the absence in life history data of childhood measures that are not well suited to retrospective collection.

Mental health and ethnic density among adolescents in England: A cross-sectional study.

This paper determines the association of neighbourhood ethnic density on adolescent mental health and its interplay with ethnic minority status and neighbourhood deprivation. 4145 cross-sectional responses to the 2009-2011 UK Household Longitudinal Study (UKHLS) youth self-completion questionnaire for youths aged 10-15 living in England were combined with household responses to the household UKHLS interview and 2011 Census data. Regression models were used to predict a Strengths and Difficulties Questionnaire (SDQ) score (range 0-40) with higher values indicating worse mental health. Ethnic density was operationalised using two distinct measures: co-ethnic density and diversity index. There was no difference in the mental health of ethnic minority youths by whether they lived in neighbourhoods of differing levels of ethnic density or neighbourhood deprivation. White British youths had poorer mental health when living in deprived neighbourhoods where their ethnic group was the vast majority. The difference compared to all other neighbourhoods was two points on the SDQ score. Interventions should seek to encourage adolescents living in white-working class neighbourhoods to explore ethnic diversity to determine whether it improves their mental health.

Are there sensitive neighbourhood effect periods during the life course on midlife health and wellbeing?

Since the turn of the century there has been an explosion in the number of epidemiological studies that have analysed neighbourhood effects on health and wellbeing. The vast majority of these studies are cross-sectional in nature and assume that a contemporaneous place of residence captures a meaningful neighbourhood effect. Over the same time frame, social epidemiology has focussed increasingly on life course effects. This paper aims to bring these two areas of study together and tests whether there a certain ages during the life course when neighbourhoods are more important for our health and wellbeing than others. We use two British birth cohort studies (1958 National Child Development Study and British Cohort Study 1970) each comprising approximately 6,000 sample members at midlife linked to historic census measures used to derived Townsend neighbourhood deprivation scores over the life course. We find little evidence to support our hypothesis that adolescence is a key period of neighbourhood effect, rather we find late-early-adulthood neighbourhood deprivation and midlife neighbourhood deprivation are more strongly related to mid-life health and wellbeing. We are not able to conclude whether these effects are causal and encourage further investigation of selection mechanisms into neighbourhoods and mediation throughout the life course using our newly created dataset.

Transitions between frailty states among community-dwelling older people: A systematic review and meta-analysis.

Frailty is a well-established risk factor for adverse health outcomes. However, comparatively little is known about the dynamic nature of frailty and the extent to which it can improve. The purposes of this study were to systematically search for studies examining frailty transitions over time among community-dwelling older people, and to synthesise pooled frailty transitions rates. Four electronic databases (Medline, Embase, PsycINFO and CINAHL) were searched in July 2018. Inclusion criteria were: prospective design, community-dwelling older people with mean age>60, using 5-item frailty phenotype criteria to define three states: robust, prefrail and frail and the numbers of participants with 9 frailty transition patterns based on frailty status at baseline and follow-up. Exclusion criteria were: selected populations, using fewer than 5 frailty phenotype criteria. Two investigators independently screened 504 studies for eligibility and identified 16 studies for this review. Data were extracted by the two investigators independently. Pooled rates of frailty transition patterns were calculated by random-effects meta-analysis. Among 42,775 community-dwelling older people from 16 studies with a mean follow-up of 3.9 years (range: 1-10 years), 13.7% (95%CI = 11.7-15.8%) improved, 29.1% (95%CI = 25.9-32.5%) worsened and 56.5% (95%CI = 54.2-58.8%) maintained the same frailty status. Among those who were robust at baseline, pooled rates of remaining robust or transitioning to prefrail and frail were 54.0% (95%CI = 48.8-59.1%), 40.6% (95%CI = 36.7-44.7%) and 4.5% (95%CI = 3.2-6.1%), respectively. Among those who were prefrail at baseline, corresponding rates to robust, prefrail and frail were 23.1% (95%CI = 18.8-27.6%), 58.2% (95%CI = 55.6-60.7%) and 18.2% (95%CI = 14.9-21.7%), respectively. Among those who were frail at baseline, pooled rates of transitioning to robust, prefrail and remaining frail were 3.3% (95%CI = 1.6-5.5%), 40.3% (95%CI = 34.6-46.1%) and 54.5% (95%CI = 47.6-61.3%), respectively. Stratified and meta-regression analyses showed age, gender and follow-up period were associated with frailty transition patterns. Older people make dynamic changes in their frailty status. Given that while one quarter of prefrail older people improved to robust only 3% of frail older people did, early interventions should be considered.