Understanding social inequalities in children being bullied: UK Millennium Cohort Study findings.

BACKGROUND: Children living in disadvantaged socio-economic circumstances (SEC) are more commonly victims of bullying, but pathways leading to social inequalities in being bullied are unclear. We assess how early life risk factors might mediate the increased risk of being bullied at age seven for children living in disadvantaged circumstances. MATERIAL AND METHODS: Using data from 5,857 children in the UK Millennium Cohort Study (MCS) we calculate risk ratios (RR) for being bullied at age seven (child-reported), by household income quintile. Socially patterned risk factors for being bullied relating to social networks, family relationships and child characteristics from birth to age five were adjusted for to assess if they mediated any association between SEC and being bullied. RESULTS: 48.6% of children reported having been bullied. Children living in the lowest income households were at 20% greater risk of being bullied compared to those from the highest (RR1.20, 95%CI 1.06,1.36). Controlling for social networks, family relationships and child characteristics attenuated the increased risk for children in low income households to aRR 1.19 (95%CI 1.05, 1.35), aRR 1.16 (95%CI 1.02,1.32) and aRR 1.13 (95%CI 1.00,1.28) respectively. Our final model adjusted for risk factors across all domains attenuated the RR by 45% (aRR 1.11,95%CI 0.97,1.26). CONCLUSIONS: About half of children reported being bullied by age seven with a clear social gradient. The excess risk in children growing up in disadvantaged circumstances was partially explained by differences in their early years relating to their social network, family relationships and the child's own abilities and behaviours. Policies to reduce inequalities in these risk factors may also reduce inequalities in the risk of being bullied in childhood.

Social patterning of telephone health-advice for diarrhoea and vomiting: analysis of 24 million telehealth calls in England.

OBJECTIVES: Gastrointestinal (GI) infections are common and most people do not see a physician. There is conflicting evidence of the impact of socioeconomic status (SES) on risk of GI infections. We assessed the relationship between SES and GI calls to two National Health Service (NHS) telephone advice services in England. METHODS: Over 24 million calls to NHS Direct (2010-13) and NHS 111 (2013-15) were extracted from Public Health England (PHE) syndromic surveillance systems. The relationship between SES and GI calls was assessed using generalised linear models (GLM). RESULTS: Adjusting for rurality and age-sex interactions, in NHS Direct, children in disadvantaged areas were at lower risk of GI calls; in NHS 111 there was a higher risk of GI calls in disadvantaged areas for all ages (0-4 years RR 1.27, 95% CI 1.25-1.29; 5-9 years RR 1.43, 95% CI 1.36-1.51; 10-14 years RR 1.36, 95% CI 1.26-1.41; 15-19 years RR 1.59, 95% CI 1.52-1.67; 20-59 years RR 1.50, 95% CI 1.47-1.53, 60 years and over RR 1.12, 95% CI 1.09-1.14). CONCLUSIONS: Disadvantaged areas had higher risk of GI calls in NHS 111. This may relate to differences in exposure or vulnerability to GI infections, or propensity to call about GI infections.

Relationship between socioeconomic status and gastrointestinal infections in developed countries: A systematic review and meta-analysis.

BACKGROUND: The association between socioeconomic status (SES) and health is well-documented; however limited evidence on the relationship between SES and gastrointestinal (GI) infections exists, with published studies producing conflicting results. This systematic review aimed to assess the association between SES and GI infection risk, and explore possible sources of heterogeneity in effect estimates reported in the literature. METHODS: MEDLINE, Scopus, Web of Science and grey literature were searched from 1980 to October 2015 for studies reporting an association between GI infections and SES in a representative population sample from a member-country of the Organisation for Economic Co-operation and Development. Harvest plots and meta-regression were used to investigate potential sources of heterogeneity such as age; level of SES variable; GI infection measurement; and predominant mode of transmission. The protocol was registered on PROSPERO: CRD42015027231. RESULTS: In total, 6021 studies were identified; 102 met the inclusion criteria. Age was identified as the only statistically significant potential effect modifier of the association between SES and GI infection risk. For children, GI infection risk was higher for those of lower SES versus high (RR 1.51, 95% CI;1.26-1.83), but there was no association for adults (RR 0.79, 95% CI;0.58-1.06). In univariate analysis, the increased risk comparing low and high SES groups was significantly higher for pathogens spread by person-to-person transmission, but lower for environmental pathogens, as compared to foodborne pathogens. CONCLUSIONS: Disadvantaged children, but not adults, have greater risk of GI infection compared to their more advantaged counterparts. There was high heterogeneity and many studies were of low quality. More high quality studies are needed to investigate the association between SES and GI infection risk, and future research should stratify analyses by age and pathogen type. Gaining further insight into this relationship will help inform policies to reduce inequalities in GI illness in children.

Socioeconomic status and infectious intestinal disease in the community: a longitudinal study (IID2 study).

Background: Infectious intestinal diseases (IID) are common, affecting around 25% of people in UK each year at an estimated annual cost to the economy, individuals and the NHS of £1.5 billion. While there is evidence of higher IID hospital admissions in more disadvantaged groups, the association between socioeconomic status (SES) and risk of IID remains unclear. This study aims to investigate the relationship between SES and IID in a large community cohort. Methods: Longitudinal analysis of a prospective community cohort in the UK following 6836 participants of all ages was undertaken. Hazard ratios for IID by SES were estimated using Cox proportional hazard, adjusting for follow-up time and potential confounding factors. Results: In the fully adjusted analysis, hazard ratio of IID was significantly lower among routine/manual occupations compared with managerial/professional occupations (HR 0.74, 95% CI 0.61-0.90). Conclusion: In this large community cohort, lower SES was associated with lower IID risk. This may be partially explained by the low response rate which varied by SES. However, it may be related to differences in exposure or recognition of IID symptoms by SES. Higher hospital admissions associated with lower SES observed in some studies could relate to more severe consequences, rather than increased infection risk.

Are social inequalities in early childhood smoking initiation explained by exposure to adult smoking? Findings from the UK Millennium Cohort Study.

INTRODUCTION: To assess the socio-economic gradient in early smoking initiation at age 11 years and the extent to which any inequality was explained after accounting for longitudinal exposure to adult smoking. METHODS: Analysis of the UK Millennium Cohort Study, based on 9, 609 children from ages 9 months to 11 years. The outcome was smoking initiation by age 11. Odds ratios (ORs) for smoking initiation were estimated using logistic regression, according to maternal education, whilst adjusting for baseline demographic factors. Longitudinal exposure to a regular smoker in the same room was assessed as potential mediator of the association between maternal education and early smoking, along with other socially patterned risk factors for early smoking initiation, such as parental separation and mental health. RESULTS: Overall 2.7% (95% CI: 2.3-3.1) of children had tried a cigarette by age eleven. Children of mothers with no qualifications were more than six times as likely to have tried a cigarette than children of mothers with degree level qualifications or higher (OR 6.0 [95%CI 3.5-10.1]), with clear social gradient. Controlling for potentially mediating variables, particularly exposure to a regular adult smoker reduced the OR smoking initiation in children of mothers with no qualifications by 63% (aOR 2.9 [95%CI 1.7 to 5.1]). CONCLUSIONS: Smoking initiation is more common in disadvantaged children, and this is largely explained by regular exposure to an adult smoker in the same room. Reducing adult smoking in front of children may reduce inequalities in smoking initiation in children by over a half.

Socioeconomic status is associated with symptom severity and sickness absence in people with infectious intestinal disease in the UK.

BACKGROUND: The burden of infectious intestinal disease (IID) in the UK is substantial. Negative consequences including sickness absence are common, but little is known about the social patterning of these outcomes, or the extent to which they relate to disease severity. METHODS: We performed a cross-sectional analysis using IID cases identified from a large population-based survey, to explore the association between socioeconomic status (SES) and symptom severity and sickness absence; and to assess the role of symptom severity on the relationship between SES and absence. Regression modelling was used to investigate these associations, whilst controlling for potential confounders such as age, sex and ethnicity. RESULTS: Among 1164 cases, those of lower SES versus high had twice the odds of experiencing severe symptoms (OR 2.2, 95%CI;1.66-2.87). Lower SES was associated with higher odds of sickness absence (OR 1.8, 95%CI;1.26-2.69), however this association was attenuated after adjusting for symptom severity (OR 1.4, 95%CI;0.92-2.07). CONCLUSIONS: In a large sample of IID cases, those of low SES versus high were more likely to report severe symptoms, and sickness absence; with greater severity largely explaining the higher absence. Public health interventions are needed to address the unequal consequences of IID identified.

Relationship between socioeconomic status and gastrointestinal infections in developed countries: a systematic review protocol.

BACKGROUND: The association between low socioeconomic status (SES) and poor health is well documented in the existing literature. Nonetheless, evidence on the relationship between SES and gastrointestinal (GI) infections is limited, and the mechanisms underlying this relationship are not well understood with published studies pointing to conflicting results. This review aims to identify studies that investigate the relationship between SES and GI infections in developed countries, in order to assess the direction of the association and explore possible explanations for any differences in the risk, incidence or prevalence of GI infections across socioeconomic groups. METHODS: Three systematic methods will be used to identify relevant literature: electronic database, reference list and grey literature searching. The databases MEDLINE, Scopus and Web of Science Core Collection will be searched using a broad range of search terms. Screening of the results will be performed by two reviewers using pre-defined inclusion and exclusion criteria. The reference lists of included studies will be searched, and Google will be used to identify grey literature. Observational studies reporting quantitative results on the prevalence or incidence of any symptomatic GI infections by SES, in a representative population sample from a member country of the Organisation for Economic Co-operation and Development (OECD), will be included. Data will be extracted using a standardised form. Study quality will be assessed using the Liverpool University Quality Assessment Tools (LQAT). A narrative synthesis will be performed including tabulation of studies for comparison. DISCUSSION: This systematic review will consolidate the existing knowledge on the relationship between SES and GI infections. The results will help to identify gaps in the literature and will therefore provide an evidence base for future empirical studies to deepen the understanding of the relationship, including effective study design and appropriate data analysis methods. Ultimately, gaining insight into this relationship will help to inform policies to reduce any health inequalities identified. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015027231.

Social inequalities in wheezing in children: findings from the UK Millennium Cohort Study.

Wheezing in childhood is socially patterned, but it is unclear what factors explain the social differences.Regression analysis of the UK Millennium Cohort Study, based on 11 141 singleton children who participated at ages 9 months and 3, 5 and 7 years. Relative risk ratios (RRR) for early and persistent/relapsing wheeze were estimated using multinomial regression, according to measures of socioeconomic circumstances. Maternal, antenatal and early-life characteristics were assessed as potential mediators.Children of mothers with no educational qualifications were more likely to have both wheeze types, compared to children of mothers with degree-level qualifications (RRR 1.53, 95% CI 1.26-1.86 for early wheeze; 1.32 95% CI 1.04-1.67 for persistent/relapsing wheeze). Controlling for maternal age, smoking during pregnancy and breastfeeding removed the elevated risk of wheezing. Male sex, maternal age, body mass index, atopy, smoking during pregnancy, preterm birth, breastfeeding, exposure to other children and furry pets were independently associated with wheezing, but the pattern of association varied between wheezing types.In this representative UK cohort, adjustment for maternal smoking during pregnancy and breastfeeding removed the socioeconomic inequalities in common wheezing phenotypes. Policies to reduce the social gradient in these risk factors may reduce inequalities in wheezing and asthma.

The effect of social deprivation on clinical outcomes and the use of treatments in the UK cystic fibrosis population: a longitudinal study.

BACKGROUND: Poorer socioeconomic circumstances have been linked with worse outcomes in cystic fibrosis. We assessed whether a relation exists between social deprivation and individual's clinical and health-care outcomes. METHODS: We did a longitudinal registry study of the UK cystic fibrosis population younger than 40 years (8055 people with 49337 observations for weight, the most commonly collected outcome, between Jan 1, 1996, and Dec 31, 2009). We assessed data for weight, height, body-mass index, percent predicted forced expiratory volume in 1 s (%FEV1), risk of Pseudomonas aeruginosa colonisation, and the use of major cystic fibrosis treatment modalities. We used mixed effects models to assess the association between small-area deprivation and clinical and health-care outcomes, adjusting for clinically important covariates. We give continuous outcomes as mean differences, and binary outcomes as odds ratios, comparing extremes of deprivation quintile. FINDINGS: Compared with the least deprived areas, children from the most deprived areas weighed less (standard deviation [SD] score -0·28, 95% CI -0·38 to -0·18), were shorter (-0·31, -0·40 to -0·21, and had a lower body-mass index (-0·13, -0·22 to -0·04), were more likely to have chronic P aeruginosa infection (odds ratio 1·89, 95% CI 1·34 to 2·66), and have a lower %FEV1 (-4·12 percentage points, 95% CI -5·01 to -3·19). These inequalities were apparent very early in life and did not widen thereafter. On a population level, after adjustment for disease severity, children in the most deprived quintile were more likely to receive intravenous antibiotics (odds ratio 2·52, 95% CI 1·92 to 3·17) and nutritional treatments (1·78, 1·44 to 2·20) compared with individuals in the least deprived quintile. Patients from the most disadvantaged areas were less likely to receive DNase or inhaled antibiotic treatment. INTERPRETATION: In the UK, children with cystic fibrosis from more disadvantaged areas have worse growth and lung function compared with children from more affluent areas, but these inequalities do not widen with advancing age. Clinicians consider deprivation status, as well as disease status, when making decisions about treatments, and this might mitigate some effects of social disadvantage. FUNDING: Medical Research Council (UK).

Deworming drugs for soil-transmitted intestinal worms in children: effects on nutritional indicators, haemoglobin and school performance.

BACKGROUND: The World Health Organization (WHO) recommends treating all school children at regular intervals with deworming drugs in areas where helminth infection is common. The WHO state this will improve nutritional status, haemoglobin, and cognition and thus will improve health, intellect, and school attendance. Consequently, it is claimed that school performance will improve, child mortality will decline, and economic productivity will increase. Given the important health and societal benefits attributed to this intervention, we sought to determine whether they are based on reliable evidence. OBJECTIVES: To summarize the effects of giving deworming drugs to children to treat soil-transmitted intestinal worms (nematode geohelminths) on weight, haemoglobin, and cognition; and the evidence of impact on physical well being, school attendance, school performance, and mortality. SEARCH METHODS: In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, EMBASE, LILACS, mRCT, and reference lists, and registers of ongoing and completed trials. SELECTION CRITERIA: We selected randomized controlled trials (RCTs) and quasi-RCTs comparing deworming drugs for geohelminth worms with placebo or no treatment in children aged 16 years or less, reporting on weight, haemoglobin, and formal test of intellectual development. In cluster-RCTs treating communities or schools, we also sought data on school attendance, school performance, and mortality. We included trials that included health education with deworming. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed the trials, evaluated risk of bias, and extracted data. Continuous data were analysed using the mean difference (MD) with 95% confidence intervals (CI). Where data were missing, we contacted trial authors. We used GRADE to assess evidence quality, and this is reflected in the wording we used: high quality ("deworming improves...."); moderate quality ("deworming probably improves..."); low quality ("deworming may improve...."); and very low quality ("we don't know if deworming improves...."). MAIN RESULTS: We identified 42 trials, including eight cluster trials, that met the inclusion criteria. Excluding one trial where data are awaited, the 41 trials include 65,168 participants.Screening then treatingFor children known to be infected with worms (by screening), a single dose of deworming drugs may increase weight (0.58 kg, 95% CI 0.40 to 0.76, three trials, 139 participants; low quality evidence) and may increase haemoglobin (0.37 g/dL, 95% CI 0.1 to 0.64, two trials, 108 participants; low quality evidence), but we do not know if there is an effect on cognitive functioning (two trials, very low quality evidence).Single dose deworming for all childrenIn trials treating all children, a single dose of deworming drugs gave mixed effects on weight, with no effects evident in seven trials, but large effects in two (nine trials, 3058 participants, very low quality evidence). The two trials with a positive effect were from the same very high prevalence setting and may not be easily generalised elsewhere. Single dose deworming probably made little or no effect on haemoglobin (mean difference (MD) 0.06 g/dL, 95% CI -0.06 to 0.17, three trials, 1005 participants; moderate evidence), and may have little or no effect on cognition (two trials, low quality evidence).Mulitple dose deworming for all childrenOver the first year of follow up, multiple doses of deworming drugs given to all children may have little or no effect on weight (MD 0.06 kg, 95% CI -0.17 to 0.30; seven trials, 2460 participants; low quality evidence); haemoglobin, (mean 0.01 g/dL lower; 95% CI 0.14 lower to 0.13 higher; four trials, 807 participants; low quality evidence); cognition (three trials, 30,571 participants, low quality evidence); or school attendance (4% higher attendance; 95% CI -6 to 14; two trials, 30,243 participants; low quality evidence);For time periods beyond a year, there were five trials with weight measures. One cluster-RCT of 3712 children in a low prevalence area showed a large effect (average gain of 0.98 kg), whilst the other four trials did not show an effect, including a cluster-RCT of 27,995 children in a moderate prevalence area (five trials, 37,306 participants; low quality evidence). For height, we are uncertain whether there is an effect of deworming (-0.26 cm; 95% CI -0.84 to 0.31, three trials, 6652 participants; very low quality evidence). Deworming may have little or no effect on haemoglobin (0.00 g/dL, 95%CI -0.08 to 0.08, two trials, 1365 participants, low quality evidence); cognition (two trials, 3720 participants; moderate quality evidence). For school attendance, we are uncertain if there is an effect (mean attendance 5% higher, 95% CI -0.5 to 10.5, approximately 20,000 participants, very low quality evidence).Stratified analysis to seek subgroup effects into low, medium and high helminth endemicity areas did not demonstrate any pattern of effect. In a sensitivity analysis that only included trials with adequate allocation concealment, we detected no significant effects for any primary outcomes.One million children were randomized in a deworming trial from India with mortality as the primary outcome. This was completed in 2005 but the authors have not published the results. AUTHORS' CONCLUSIONS: Screening children for intestinal helminths and then treating infected children appears promising, but the evidence base is small. Routine deworming drugs given to school children has been more extensively investigated, and has not shown benefit on weight in most studies, except for substantial weight changes in three trials conducted 15 years ago or more. Two of these trials were carried out in the same high prevalence setting. For haemoglobin and cognition, community deworming seems to have little or no effect, and the evidence in relation to school attendance, and school performance is generally poor, with no obvious or consistent effect. Our interpretation of this data is that it is probably misleading to justify contemporary deworming programmes based on evidence of consistent benefit on nutrition, haemoglobin, school attendance or school performance as there is simply insufficient reliable information to know whether this is so.

Deworming drugs for soil-transmitted intestinal worms in children: effects on nutritional indicators, haemoglobin and school performance.

BACKGROUND: The World Health Organization (WHO) recommends treating all school children at regular intervals with deworming drugs in areas where helminth infection is common. The WHO state this will improve nutritional status, haemoglobin, and cognition and thus will improve health, intellect, and school attendance. Consequently, it is claimed that school performance will improve, child mortality will decline, and economic productivity will increase. Given the important health and societal benefits attributed to this intervention, we sought to determine whether they are based on reliable evidence. OBJECTIVES: To summarize the effects of giving deworming drugs to children to treat soil-transmitted intestinal worms (nematode geohelminths) on weight, haemoglobin, and cognition; and the evidence of impact on physical well being, school attendance, school performance, and mortality. SEARCH METHODS: In February 2012, we searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, EMBASE, LILACS, mRCT, and reference lists, and registers of ongoing and completed trials. SELECTION CRITERIA: We selected randomized controlled trials (RCTs) and quasi-RCTs comparing deworming drugs for geohelminth worms with placebo or no treatment in children aged 16 years or less, reporting on weight, haemoglobin, and formal test of intellectual development. In cluster-RCTs treating communities or schools, we also sought data on school attendance, school performance, and mortality. We included trials that included health education with deworming. DATA COLLECTION AND ANALYSIS: At least two authors independently assessed the trials, evaluated risk of bias, and extracted data. Continuous data were analysed using the mean difference (MD) with 95% confidence intervals (CI). Where data were missing, we contacted trial authors. We used GRADE to assess evidence quality, and this is reflected in the wording we used: high quality ("deworming improves...."); moderate quality ("deworming probably improves..."); low quality ("deworming may improve...."); and very low quality ("we don't know if deworming improves...."). MAIN RESULTS: We identified 42 trials, including eight cluster trials, that met the inclusion criteria. Excluding one trial where data are awaited, the 41 trials include 65,168 participants.For programmes that treat only children detected as infected (by screening), a single dose of deworming drugs probably increased weight (0.58 kg, 95% CI 0.40 to 0.76, three trials, 139 participants; moderate quality evidence) and may have increased haemoglobin (0.37 g/dL, 95% CI 0.1 to 0.64, two trials, 108 participants; low quality evidence), but we do not know if there is an effect on cognitive functioning (two trials, very low quality evidence).For a single dose of deworming drugs given to all children in endemic areas, there were mixed effects on weight, with no effects evident in seven trials, but large effects in two. Overall our analysis indicated that we are uncertain whether there was an effect on weight (nine trials, 3058 participants; very low quality evidence). For haemoglobin, deworming made little or no difference (0.02 g/dL, 95% CI -0.05 to 0.09, four trials, 1992 participants; low quality evidence), and we don't know if it improves cognition (one trial, very low quality evidence).For multiple doses of deworming drugs with follow up for up to one year given to all children in endemic areas, we are uncertain if there is an effect on weight (0.06 kg, 95% CI -0.17 to 0.30; seven trials, 2460 participants; very low quality evidence); cognition (three trials, very low quality evidence); or school attendance (4% higher attendance; 95% CI -6 to 14; two trials, 75 clusters and 143 individually randomized participants, very low quality evidence). For haemoglobin, the intervention may have little or no effect (mean 0.01 g/dL lower; 95% CI 0.14 lower to 0.13 higher; four trials, 807 participants; low quality evidence).For multiple doses of deworming drugs with follow up beyond one year given to all children in endemic areas there were five trials with weight measures. One cluster-RCT of 3712 children in a low prevalence area showed a large effect (average gain of 0.98kg), whilst the other four trials did not show an effect, including a cluster-RCT of 27,995 children in a moderate prevalence area. Overall, we are uncertain if there is an effect for weight (five trials, 302 clusters and 1045 individually randomized participants; very low quality evidence). For other outcomes, we are uncertain whether deworming affects height (-0.26 cm; 95%CI -0.84 to 0.31, three trials, 1219 participants); haemoglobin (0.02 g/dL, 95%CI 0.3 to 0.27, two trials, 1365 participants); cognition (two trials), or school attendance (mean attendance 5% higher, 95% CI -0.5 to 10.5, one trial, 50 clusters).Stratified analysis to seek subgroup effects into low, medium and high helminth endemicity areas did not demonstrate any pattern of effect. We did not detect any significant effects for any primary outcomes in a sensitivity analysis only including trials with adequate allocation concealment.One million children were randomized in a deworming trial from India with mortality as the primary outcome. This was completed in 2005 but the authors have not published the results. AUTHORS' CONCLUSIONS: Screening children for intestinal helminths and then treating infected children appears promising, but the evidence base is small. Routine deworming drugs given to school children has been more extensively investigated, and has not shown benefit on weight in most studies, except for substantial weight changes in three trials conducted 15 years ago or more. Two of these trials were carried out in the same high prevalence setting. For haemoglobin, community deworming seems to have little or no effect, and the evidence in relation to cognition, school attendance, and school performance is generally poor, with no obvious or consistent effect. Our interpretation of this data is that it is probably misleading to justify contemporary deworming programmes based on evidence of consistent benefit on nutrition, haemoglobin, school attendance or school performance as there is simply insufficient reliable information to know whether this is so.

Prioritising public health: a qualitative study of decision making to reduce health inequalities.

BACKGROUND: The public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study. METHODS: We conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff. RESULTS: The short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms. CONCLUSIONS: It is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.

Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making.

BACKGROUND: In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making. METHODS: Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified. RESULTS: Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established. CONCLUSION: Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.