'It depends on where you were born here in the North East, there's not really many job opportunities compared to in the South': young people's perspectives on a North-South health divide and its drivers in England, UK.

BACKGROUND: Improving the public's understanding of how regional and socioeconomic inequalities create and perpetuate inequalities in health, is argued to be necessary for building support for policies geared towards creating a more equal society. However, research exploring public perceptions of health inequalities, and how they are generated, is limited. This is particularly so for young people. Our study sought to explore young people's lived experiences and understandings of health inequalities. METHODS: We carried out focus group discussions (n = 18) with 42 young people, aged 13-21, recruited from six youth organisations in England in 2021. The organisations were located in areas of high deprivation in South Yorkshire, the North East and London. Young people from each organisation took part in three interlinked focus group discussions designed to explore their (i) perceptions of factors impacting their health in their local area, (ii) understandings of health inequalities and (iii) priorities for change. Due to the Covid-19 pandemic, most discussions took place online (n = 15). However, with one group in the North East, we carried out discussions face-to-face (n = 3). Data were analysed thematically and we used NVivo-12 software to facilitate data management. RESULTS: Young people from all groups demonstrated an awareness of a North-South divide in England, UK. They described how disparities in local economies and employment landscapes between the North and the South led to tangible differences in everyday living and working conditions. They clearly articulated how these differences ultimately led to inequalities in people's health and wellbeing, such as linking poverty and employment precarity to chronic stress. Young people did not believe these inequalities were inevitable. They described the Conservative government as prioritising the South and thus perpetuating inequalities through uneven investment. CONCLUSIONS: Our study affords important insights into young people's perceptions of how wider determinants can help explain the North-South health divide in England. It demonstrates young people's contextualised understandings of the interplay between spatial, social and health inequalities. Our findings support calls for pro-equity policies to address the structural causes of regional divides in health. Further research, engaging young people in deliberative policy analysis, could build on this work.

Young people's perspectives on policies to create healthier food environments in England.

Food environments are important determinants of healthy diets among young people. This study explored young people's perspectives on their food environment, their recommendations to policymakers and views on youth engagement in policy processes. There is limited research on young people's perspectives on their involvement in developing food environment policies. Youth engagement in policymaking processes can lead to greater policy integrity and inclusivity. Four focus group discussions were conducted with 39 young people (12-21 years) from a town in North West England and a metropolitan area in the English Midlands. Participants were recruited through youth organizations. Data were analysed using inductive thematic analysis. Young people reported concerns about the density of fast food outlets in their local area, the unaffordability of healthier food, and fast food advertisement. These issues were not believed to be prioritized in local and national policymaking. Accordingly, policy recommendations were mainly for structural food environment policies, including restrictions on fast food outlet density and incentives for menu reformulation. Young people did not feel involved in local decisions about the food environment. They expressed a need for more meaningful engagement beyond consultation. Young people have repeatedly shown to have a deep understanding of the social, commercial and political factors that influence diet and health. It is essential that policymakers aiming to improve young people's diets take their unique views and concerns into account to create effective policies that resonate with young people.

Young people's views and experience of diet-related inequalities in England (UK): a qualitative study.

Inequalities in diets contribute to overall inequalities in health. Economic inequality and inequalities in access to healthy food are key drivers of poor diet and ill health among young people (YP). Despite mounting evidence of structural barriers to healthy eating, less is known about how YP view and experience these inequalities where they live, and how to address them. To explore YP's perspectives on the drivers of diet-related health inequalities, we conducted three interlinked focus groups with YP aged 13-21 years from six youth groups across three geographical areas in England. We analysed the data inductively and deductively using reflexive thematic analysis and generated themes by examining how social structure, context and agency interact and impact YP's diet. YP were aware of how inequalities in employment conditions impact their families' income and ability to eat a healthy diet. They cited the high availability of hot food takeaways in their local areas as a significant barrier to healthy eating but did not support closing or restricting these outlets. They held strong views on policies to tackle diet inequality and showed a nuanced understanding of the strengths and limitations of universal and targeted approaches. Our study showed that YP have an awareness and understanding of food as important in relation to health, and of diet-related inequalities. However, further efforts are needed to shape and promote policies that resonate with YP and address both their health and wider social concerns.

Inequalities in local government spending on cultural, environmental and planning services: a time-trend analysis in England, Scotland, and Wales.

BACKGROUND: Local government provides Cultural, Environmental, and Planning (CEP) services, such as parks, libraries, and waste collection, that are vital for promoting health and wellbeing. There have been significant changes to the funding of these services over the past decade, most notably due to the UK government's austerity programme. These changes have not affected all places equally. To understand potential impacts on health inequalities, we investigated geographical patterning of recent CEP spending trends. METHODS: We conducted a time trend analysis using routinely available data on local government expenditure. We used generalised estimating equations to determine how expenditure trends varied across 378 local authorities (LAs) in Great Britain between 2009/10 and 2018/19 on the basis of country, deprivation, rurality, and local government structure. We investigated the gross expenditure per capita on CEP services, and the CEP expenditure as a proportion of total local authority budgets. We present the estimated annual percentage change in these spend measures. RESULTS: Expenditure per capita for CEP services reduced by 36% between 2009/10 and 2018/19. In England, the reduction in per capita spending was steepest in the most deprived quintile of areas, falling by 7.5% [95% CI: 6.0, 8.9] per year, compared to 4.5% [95% CI: 3.3, 5.6] per year in the least deprived quintile. Budget cuts in Scotland and Wales have been more equitable, with similar trends in the most and least deprived areas. Welsh LAs have reduced the proportion of total LA budget spent on CEP services the most (-4.0% per year, 95% CI: -5.0 to -2.9), followed by Scotland (-3.0% per year, 95% CI: -4.2 to -1.7) then England (-1.4% per year, 95% CI: -2.2 to -0.6). In England, rural and unitary LAs reduced their share of spending allocated to CEP more than urban and two-tier structured LAs, respectively. CONCLUSION: Funding for cultural, environmental and planning services provided by local government in the UK has been cut dramatically over the last decade, with clear geographical inequalities. Local areas worst affected have been those with a higher baseline level of deprivation, those with a single-tier local government structure, and English rural local authorities. The inequalities in cuts to these services risk widening geographical inequalities in health and wellbeing.

Changes in household food and drink purchases following restrictions on the advertisement of high fat, salt, and sugar products across the Transport for London network: A controlled interrupted time series analysis.

BACKGROUND: Restricting the advertisement of products with high fat, salt, and sugar (HFSS) content has been recommended as a policy tool to improve diet and tackle obesity, but the impact on HFSS purchasing is unknown. This study aimed to evaluate the impact of HFSS advertising restrictions, implemented across the London (UK) transport network in February 2019, on HFSS purchases. METHODS AND FINDINGS: Over 5 million take-home food and drink purchases were recorded by 1,970 households (London [intervention], n = 977; North of England [control], n = 993) randomly selected from the Kantar Fast Moving Consumer Goods panel. The intervention and control samples were similar in household characteristics but had small differences in main food shopper sex, socioeconomic position, and body mass index. Using a controlled interrupted time series design, we estimated average weekly household purchases of energy and nutrients from HFSS products in the post-intervention period (44 weeks) compared to a counterfactual constructed from the control and pre-intervention (36 weeks) series. Energy purchased from HFSS products was 6.7% (1,001.0 kcal, 95% CI 456.0 to 1,546.0) lower among intervention households compared to the counterfactual. Relative reductions in purchases of fat (57.9 g, 95% CI 22.1 to 93.7), saturated fat (26.4 g, 95% CI 12.4 to 40.4), and sugar (80.7 g, 95% CI 41.4 to 120.1) from HFSS products were also observed. Energy from chocolate and confectionery purchases was 19.4% (317.9 kcal, 95% CI 200.0 to 435.8) lower among intervention households than for the counterfactual, with corresponding relative reductions in fat (13.1 g, 95% CI 7.5 to 18.8), saturated fat (8.7 g, 95% CI 5.7 to 11.7), sugar (41.4 g, 95% CI 27.4 to 55.4), and salt (0.2 g, 95% CI 0.1 to 0.2) purchased from chocolate and confectionery. Relative reductions are in the context of secular increases in HFSS purchases in both the intervention and control areas, so the policy was associated with attenuated growth of HFSS purchases rather than absolute reduction in HFSS purchases. Study limitations include the lack of out-of-home purchases in our analyses and not being able to assess the sustainability of observed changes beyond 44 weeks. CONCLUSIONS: This study finds an association between the implementation of restrictions on outdoor HFSS advertising and relative reductions in energy, sugar, and fat purchased from HFSS products. These findings provide support for policies that restrict HFSS advertising as a tool to reduce purchases of HFSS products.

Power, control, communities and health inequalities I: theories, concepts and analytical frameworks.

This is Part I of a three-part series on community empowerment as a route to greater health equity. We argue that community 'empowerment' approaches in the health field are increasingly restricted to an inward gaze on community psycho-social capacities and proximal neighbourhood conditions, neglecting the outward gaze on political and social transformation for greater equity embedded in foundational statements on health promotion. We suggest there are three imperatives if these approaches are to contribute to increased equity. First, to understand pathways from empowerment to health equity and drivers of the depoliticisation of contemporary empowerment practices. Second, to return to the original concept of empowerment processes that support communities of place/interest to develop capabilities needed to exercise collective control over decisions and actions in the pursuit of social justice. Third, to understand, and engage with, power dynamics in community settings. Based on our longitudinal evaluation of a major English community empowerment initiative and research on neighbourhood resilience, we propose two complementary frameworks to support these shifts. The Emancipatory Power Framework presents collective control capabilities as forms of positive power. The Limiting Power Framework elaborates negative forms of power that restrict the development and exercise of a community's capabilities for collective control. Parts II and III of this series present empirical findings on the operationalization of these frameworks. Part II focuses on qualitative markers of shifts in emancipatory power in BL communities and Part III explores how power dynamics unfolded in these neighbourhoods.

Power, control, communities and health inequalities. Part II: measuring shifts in power.

In the health field, there is great interest in the role empowerment might play in reducing social inequalities in health. Empowerment is understood here as the processes of developing capabilities that individuals and/or communities need to exercise control over decisions and actions impacting on their lives and health. There is a fundamental problem, however, in identifying and measuring capabilities for collective control that emerge at the level of the collective, with much of the existing literature focusing on individual measures even where community-level processes are concerned. Collective measures need to capture the dynamics of interactions within and between groups, not simply aggregate individual-level measures. This article, Part 2 in a three-part series, takes up the challenge of identifying qualitative markers of capabilities for collective control. We applied the emancipatory power framework (EPF) reported in Part 1 of the series, to qualitative data generated during a longitudinal evaluation of a major English area-based empowerment initiative, the Big Local (BL). We identified empirical 'markers' of shifts towards greater collective control pertaining to each of the 'power' dimensions in the EPF-'power within', 'power with' and 'power to'-and markers of communities exercising 'power over' other institutions/community members. These markers can usefully be applied in the evaluation planning and evaluation of empowerment initiatives. Part 3 in the series uses these markers and a second analytical framework developed during our evaluation of BL to explore how power dynamics unfold in participatory spaces in BL neighbourhoods.

Qualitative process evaluation from a complex systems perspective: A systematic review and framework for public health evaluators.

BACKGROUND: Public health evaluation methods have been criticized for being overly reductionist and failing to generate suitable evidence for public health decision-making. A "complex systems approach" has been advocated to account for real world complexity. Qualitative methods may be well suited to understanding change in complex social environments, but guidance on applying a complex systems approach to inform qualitative research remains limited and underdeveloped. This systematic review aims to analyze published examples of process evaluations that utilize qualitative methods that involve a complex systems perspective and proposes a framework for qualitative complex system process evaluations. METHODS AND FINDINGS: We conducted a systematic search to identify complex system process evaluations that involve qualitative methods by searching electronic databases from January 1, 2014-September 30, 2019 (Scopus, MEDLINE, Web of Science), citation searching, and expert consultations. Process evaluations were included if they self-identified as taking a systems- or complexity-oriented approach, integrated qualitative methods, reported empirical findings, and evaluated public health interventions. Two reviewers independently assessed each study to identify concepts associated with the systems thinking and complexity science traditions. Twenty-one unique studies were identified evaluating a wide range of public health interventions in, for example, urban planning, sexual health, violence prevention, substance use, and community transformation. Evaluations were conducted in settings such as schools, workplaces, and neighborhoods in 13 different countries (9 high-income and 4 middle-income). All reported some utilization of complex systems concepts in the analysis of qualitative data. In 14 evaluations, the consideration of complex systems influenced intervention design, evaluation planning, or fieldwork. The identified studies used systems concepts to depict and describe a system at one point in time. Only 4 evaluations explicitly utilized a range of complexity concepts to assess changes within the system resulting from, or co-occurring with, intervention implementation over time. Limitations to our approach are including only English-language papers, reliance on study authors reporting their utilization of complex systems concepts, and subjective judgment from the reviewers relating to which concepts featured in each study. CONCLUSION: This study found no consensus on what bringing a complex systems perspective to public health process evaluations with qualitative methods looks like in practice and that many studies of this nature describe static systems at a single time point. We suggest future studies use a 2-phase framework for qualitative process evaluations that seek to assess changes over time from a complex systems perspective. The first phase involves producing a description of the system and identifying hypotheses about how the system may change in response to the intervention. The second phase involves following the pathway of emergent findings in an adaptive evaluation approach.

'A true partner around the table?' Perceptions of how to strengthen public health's contributions to the alcohol licensing process.

INTRODUCTION: There are increased opportunities for public health practitioners (PHPs) in England to shape alcohol availability and reduce harms through a statutory role in licensing processes in local government. However, how public health can effectively influence alcohol licence decision-making is little understood. METHODS: A mixed methods study was conducted to identify challenges faced by PHPs and mechanisms to strengthen their role. This involved a survey of practitioners across London local authorities (n = 18) and four focus group discussions with a range of licensing stakeholders (n = 36). RESULTS: Survey results indicated a varied picture of workload, capacity to respond to licence applications and levels of influence over decision-making among PHPs in London. Practitioners described a felt lack of status within the licence process, and difficulties using and communicating public health evidence effectively, without a health licensing objective. Strategies considered supportive included engaging with other responsible authorities and developing understanding and relationships over time. CONCLUSIONS: Against political and resource constraints at local and national government levels, pragmatic approaches for strengthening public health influence over alcohol licensing are required, including promoting relationships between stakeholders and offering opportunities for PHPs to share best practice about making effective contributions to licensing.

Capturing complexity in the evaluation of a major area-based initiative in community empowerment: what can a multi-site, multi team, ethnographic approach offer?

In recent years, there has been growing emphasis on the need to develop ways of capturing 'complexity' in the evaluation of health initiatives in order to produce better evidence about 'how' and under what conditions such interventions work. Used alone, conventional methods of evaluation that attempt to reduce intervention processes and outcomes to a small number of discrete and finite variables, are typically not well suited to this task. Among the research community there have been increasing calls to take more seriously qualitative methods as an alternative or complementary approach to intervention evaluation. Ethnography has been identified as being particularly well suited to the purpose of capturing the full messiness that ensues when health interventions are introduced into complex settings (or systems). In this paper we reflect on our experience of taking a long term multi-site, multi team, ethnographic approach to capture complex, dynamic system processes in the first phase of an evaluation of a major area-based community empowerment initiative being rolled out in 150 neighbourhoods in England. We consider the utility of our approach for capturing the complexity inherent to understanding the changes that ensue when the initiative is delivered into multiple diverse contexts/systems as well as the opportunities and challenges that emerge in the research process.

Increasing powers to reject licences to sell alcohol: Impacts on availability, sales and behavioural outcomes from a novel natural experiment evaluation.

Excessive alcohol consumption leads to negative health and social impacts at individual and population levels. Interventions that aim to limit the density of alcohol retail premises (including cumulative impact policies (CIPs)) have been associated with decreases in alcohol-related crime and alcohol-related hospital admissions. We evaluated the quantitative impact of introducing a new alcohol licensing policy that included a comprehensive Cumulative Impact Policy (CIP) enforced in seven Cumulative Impact Zones (CIZs) in one English Local Authority in 2013. We used time series analysis to assess immediate and longer term impacts on licensing decisions and intermediate outcomes, including spatial and temporal alcohol availability, crime, alcohol-related ambulance call-outs and on-licence alcohol retail sales across the Local Authority and in CIZs and non-CIZs during the period 2008 to 2016. We found no impact on licence application rates but post-intervention applications involved fewer trading hours. Application approvals declined initially but not over the longer term. Longer term, small reductions in units of alcohol sold in bars (-2060, 95% confidence interval (CI) = -3033, -1087) were observed in areas with more intensive licensing policies ('Cumulative Impact Zones' (CIZs)). Significant initial declines in overall crime rates (CIZs = -12.2%, 95% CI = -18.0%, -6.1%; non-CIZs = -8.0%, 95% CI = -14.0%, -1.6%) were only partially reversed by small, longer term increases. Ambulance callout rates did not change significantly. The intervention was partially successful but a more intensive and sustained implementation may be necessary for longer term benefits.

Exploring the impact of public health teams on alcohol premises licensing in England and Scotland (ExILEnS): procotol for a mixed methods natural experiment evaluation.

BACKGROUND: Recent regulatory changes in the system by which premises are licensed to sell alcohol, have given health representatives a formal role in the process in England and Scotland. The degree to which local public health teams engage with this process varies by locality in both nations, which have different licensing regimes. This study aims to critically assess the impact on alcohol-related harms - and mechanisms - of public health stakeholders' engagement in alcohol premises licensing from 2012 to 2018, comparing local areas with differing types and intensities of engagement, and examining practice in Scotland and England. METHODS: The study will recruit 20 local authority areas where public health stakeholders have actively engaged with the alcohol premises licensing system (the 'intervention') and match them to a group of 20 lower activity areas using genetic matching. Four work packages are included: (1) Structured interviews and documentary analysis will examine the type and level of intervention activity from 2012 to 2018, creating a novel composite measure of the intensity of such activity and will assess the local licensing system and potential confounding activities over the same period. In-depth interviews with public health, licensing, police and others will explore perceived mechanisms of change, acceptability, and impact. (2) Using longitudinal growth models and time series analyses, the study will evaluate the impact of high and low levels of activity on alcohol-related harms using routine data from baseline 2009 to 2018. (3) Intervention costs, estimated National Health Service cost savings and health gains will be evaluated using the Sheffield Alcohol Policy Model to estimate impact on alcohol consumption and health inequalities. (4) The study will engage public health teams to create a new theory of change for public health involvement in the licensing process using our data. We will share findings with local, national and international stakeholders. DISCUSSION: This interdisciplinary study examines, for the first time, whether and how public health stakeholders' involvement in alcohol licensing impacts on alcohol harms. Using mixed methods and drawing on complex systems thinking, it will make an important contribution to an expanding literature evaluating interventions not suited to traditional epidemiological research.

E-cigarettes and equity: a systematic review of differences in awareness and use between sociodemographic groups.

OBJECTIVE: To assess whether electronic cigarette (e-cigarette) awareness, 'ever use' and current use vary significantly between different sociodemographic groups. DESIGN: Systematic review. DATA SOURCES: Published and unpublished reports identified by searching seven electronic databases (PubMed, MEDLINE, Web of Science, EMBASE, Global Health, PsycINFO, CINAHL Plus) and grey literature sources. STUDY SELECTION: Systematic search for and appraisal of cross-sectional or longitudinal studies that assessed e-cigarette awareness, 'ever use' or current use, and included subgroup analysis of 1 or more PROGRESS Plus sociodemographic groups. No geographical or time restrictions imposed. Assessment by multiple reviewers, with 17% of full articles screened meeting the selection criteria. DATA EXTRACTION: Data extracted and checked by multiple reviewers, with quality assessed using an adapted tool developed by the Joanna Briggs Institute. DATA SYNTHESIS: Results of narrative synthesis suggest broadly that awareness, 'ever use' and current use of e-cigarettes may be particularly prevalent among older adolescents and younger adults, males, people of white ethnicity and-particularly in the case of awareness and 'ever use'-those of intermediate or high levels of education. In some cases, results also varied within and between countries. CONCLUSIONS: E-cigarette awareness, 'ever use' and current use appear to be patterned by a number of sociodemographic factors which vary between different countries and subnational localities. Care will therefore be required to ensure neither the potential benefits nor the potential risks of e-cigarettes exacerbate existing health inequalities.

Reducing the Strength: a mixed methods evaluation of alcohol retailers' willingness to voluntarily reduce the availability of low cost, high strength beers and ciders in two UK local authorities.

BACKGROUND: Reducing the Strength is an increasingly popular intervention in which local authorities ask retailers to stop selling 'super-strength' beers and ciders. The intervention cannot affect alcohol availability, nor consumption, unless retailers participate. In this paper, we ask whether and why retailers choose or refuse to self-impose restrictions on alcohol sales in this way. METHODS: Mixed method assessment of retailers' participation in Reducing the Strength in two London (UK) local authorities. Compliance rates and the cheapest available unit of alcohol at each store were assessed. Qualitative interviews with retailer managers and staff (n = 39) explored attitudes towards the intervention and perceptions of its impacts. RESULTS: Shops selling super-strength across both areas fell from 78 to 25 (18 % of all off-licences). The median price of the cheapest unit of alcohol available across all retailers increased from £0.29 to £0.33 and in shops that participated in Reducing the Strength it rose from £0.33 to £0.43. The project received a mixed response from retailers. Retailers said they participated to deter disruptive customers, reduce neighbourhood disruptions and to maintain a good relationship with the local authority. Reducing the Strength participants and non-participants expressed concern about its perceived financial impact due to customers shopping elsewhere for super-strength. Some felt that customers' ability to circumvent the intervention would limit its effectiveness and that a larger scale compulsory approach would be more effective. CONCLUSIONS: Reducing the Strength can achieve high rates of voluntary compliance, reduce availability of super-strength and raise the price of the cheapest available unit of alcohol in participating shops. Questions remain over the extent to which voluntary interventions of this type can achieve wider social or health goals if non-participating shops attract customers from those who participate.

Does better than expected life expectancy in areas of disadvantage indicate health resilience? Stakeholder perspectives and possible explanations.

Some places have better than expected health trends despite being disadvantaged in other ways. Thematic analysis of qualitative data from stakeholders (N = 25) in two case studies of disadvantaged local authorities the North West and South East of England assessed explanations for the localities' apparent health resilience. Participants identified ways of working that might contribute to improved life expectancy, such as partnering with third sector, targeting and outcome driven action. Stakeholders were reluctant to assume credit for better-than-expected health outcomes. External factors such as population change, national politics and finances were considered crucial. Local public health stakeholders regard their work as important but unlikely to cause place-centred health resilience.

The effectiveness, cost-effectiveness and policy processes of regulatory, voluntary and partnership policies to improve food environments: an evidence synthesis.

Background: Dietary factors are among the largest and costliest drivers of chronic diseases in England. As a response, the government implements a range of population interventions to promote healthy diets by targeting food environments. Objectives: This study aimed to conduct a systematic review of the effectiveness, cost-effectiveness and policy process of real-world evaluations of national and state policies on improving food environments, with a focus on whether they were regulatory, voluntary or partnership approaches. Data sources: Fourteen relevant English-language databases were searched in November 2020 for studies published between 2010 and 2020. Methods: Six separate evidence reviews were conducted to assess the evidence of effectiveness, cost-effectiveness and policy processes of policies to improve food environments. Results: A total of 483 primary research evaluations and 14 evidence syntheses were included. The study reveals considerable geographic, methodological and other imbalances across the literature, with, for example, 81% of publications focusing only on 12 countries. The systematic reviews also reveal the effectiveness and cost-effectiveness of reviewed regulatory approaches designed to improve health, consumer behaviour and food environment outcomes while public-private partnerships and voluntary approaches to improve diets via reformulation, advertising and promotion restrictions or other changes to the environment were limited in their effectiveness and cost-effectiveness. The study also revealed key enabling and impeding factors across regulatory, voluntary and public-private partnership approaches. Conclusion: From the available evidence reviewed, this study finds that regulatory approaches appear most effective at improving the food environment, and voluntary agreements and partnerships have limited effectiveness. These findings should be carefully considered in future public health policy development, as should the findings of geographic imbalance in the evidence and inadequate representation of equity dimensions across the policy evaluations. We find that food policies are at times driven by factors other than the evidence and shaped by compromise and pragmatism. Food policy should be first and foremost designed and driven by the evidence of greatest effectiveness to improve food environments for healthier diets. Limitations: This was a complex evidence synthesis due to its scope and some policy evaluations may have been missed as the literature searches did not include specific policy names. The literature was limited to studies published in English from 2010 to 2020, potentially missing studies of interest. Future work: Priorities include the need for guidance for appraising risk of bias and quality of non-clinical studies, for reporting policy characteristics in evaluations, for supporting evaluations of real-world policies equitably across geographic regions, for capturing equity dimensions in policy evaluations, and for guideline development for quality and risk of bias of policy evaluations. Study registration: This study is registered as PROSPERO CRD42020170963. Funding: This award project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128607) and is published in full in Public Health Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Poor diet is a leading cause of death, globally, including in the United Kingdom. It also causes many types of illness and is one of the biggest drains on the United Kingdom National Health Service budget. Governments act in various ways to promote healthy diets by improving food environments: these are the physical and social surroundings that influence what and how much people eat. Some actions are regulated by government, for example, to control food production, marketing and promotions. Other actions are led by, or with, food businesses, making voluntary changes to the foods they produce, for example, by reducing salt content; this can be done by businesses alone or in partnership with government (referred to as 'public­private partnerships'). The six reviews of published research look at whether, and how, these actions to improve diets work, and whether they can provide value for money. Most regulations appear to be effective at supporting better diets. However, voluntary changes led by businesses had limited success. There were not many evaluations that assessed the effectiveness of public­private partnerships. Of those that did, partnerships with the food industry had limited effectiveness, resulting in largely unchanged outcomes. When looking at how these actions improve diets, we found that clear leadership, public support for the policy, the use of the best evidence and of local expertise helped with getting actions implemented. Factors that appear to make it harder to implement policy actions include a lack of evidence specific to the context, conflicting beliefs about what works, limited human or financial resources, lack of engagement by key people. Although the findings may help us to think about the ways forward to improve diets, more research is needed to understand whether actions to reduce diet-related ill health work, and provide value for money.

Factors influencing public health engagement in alcohol licensing in England and Scotland including legal and structural differences: comparative interview analysis.

Background: Greater availability of alcohol is associated with higher consumption and harms. The legal systems, by which premises are licensed to sell alcohol in England and Scotland, differ in several ways. The 'Exploring the impact of alcohol licensing in England and Scotland' study measured public health team activity regarding alcohol licensing from 2012 to 2019 and identified seven differences between England and Scotland in the timing and type of activities undertaken. Objectives: To qualitatively describe the seven previously identified differences between Scotland and England in public health approaches to alcohol licensing, and to examine, from the perspective of public health professionals, what factors may explain these differences. Methods: Ninety-four interviews were conducted with 52 professionals from 14 English and 6 Scottish public health teams selected for diversity who had been actively engaging with alcohol licensing. Interviews focused primarily on the nature of their engagement (n = 66) and their rationale for the approaches taken (n = 28). Interview data were analysed thematically using NVivo. Findings were constructed by discussion across the research team, to describe and explain the differences in practice found. Findings: Diverse legal, practical and other factors appeared to explain the seven differences. (1) Earlier engagement in licensing by Scottish public health teams in 2012-3 may have arisen from differences in the timing of legislative changes giving public health a statutory role and support from Alcohol Focus Scotland. (2) Public Health England provided significant support from 2014 in England, contributing to an increase in activity from that point. (3) Renewals of statements of licensing policy were required more frequently in Scotland and at the same time for all Licensing Boards, probably explaining greater focus on policy in Scotland. (4) Organisational structures in Scotland, with public health stakeholders spread across several organisations, likely explained greater involvement of senior leaders there. (5) Without a public health objective for licensing, English public health teams felt less confident about making objections to licence applications without other stakeholders such as the police, and instead commonly negotiated conditions on licences with applicants. In contrast, Scottish public health teams felt any direct contact with applicants was inappropriate due to conflicts of interest. (6) With the public health objective in Scotland, public health teams there were more active in making independent objections to licence applications. Further in Scotland, licensing committee meetings are held to consider all new applications regardless of whether objections have been submitted; unlike in England where there was a greater incentive to resolve objections, because then a meeting was not required. (7) Finally, Scottish public health teams involved the public more in licensing process, partly because of statutory licensing forums there. Conclusions: The alcohol premises licensing systems in England and Scotland differ in important ways including and beyond the lack of a public health objective for licensing in England. These and other differences, including support of national and local bodies, have shaped opportunities for, and the nature of, public health engagement. Further research could examine the relative success of the approaches taken by public health teams and how temporary increases in availability are handled in the two licensing systems. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Reseacrh programme as award number 15/129/11.

When alcohol becomes more widely available, harms tend to increase. In England and Scotland, this availability is controlled by local councils. They 'licence' shops, bars and other venues to allow them to sell alcohol. Local health teams, including doctors, often advise councils on licensing. In earlier work, we found seven differences in what Scottish and English health teams do on licensing. In this study, we explore these seven differences and why they came about. To do this, we interviewed 94 professionals working in public health across both countries. Scottish health teams got involved in licensing earlier than in England. This was partly because of when certain laws changed. Also, they were helped earlier by national organisations that try to reduce harm from alcohol. Scottish teams were more involved in local policies on licensing. This was probably because these policies changed more often in the Scottish system. Scottish teams involved the public more. This was partly because Scottish councils must set up 'local licensing forums'. Scottish teams also objected more often to licence applications. They generally felt that they could be more actively involved, because of a law in Scotland that says licensing must protect public health. This law does not apply in England. In England, health teams were more likely to talk to businesses that wanted licences. They were less likely to try to block applications. When they agreed changes to applications with businesses instead of objecting, fewer formal licensing meetings were needed. This was not the case in Scotland. Also, Scottish teams did not feel it was okay for them to talk to businesses. In summary, there are important differences in licensing law between Scotland and England. These matter for how health teams in the two countries engage with local councils, businesses and the public on licensing matters.

Inequalities in Research on Food Environment Policies: An Evidence Map of Global Evidence from 2010-2020.

There has been increasing pressure to implement policies for promoting healthy food environments worldwide. We conducted an evidence map to critically explore the breadth and nature of primary research from 2010-2020 that evaluated the effectiveness, cost-effectiveness, development, and implementation of mandatory and voluntary food environment policies. Fourteen databases and 2 websites were searched for "real-world" evaluations of international, national, and state level policies promoting healthy food environments. We documented the policy and evaluation characteristics, including the World Cancer Research Fund International NOURISHING framework's policy categories and 10 equity characteristics using the PROGRESS-Plus framework. Data were synthesized using descriptive statistics and visuals. We screened 27,958 records, of which 482 were included. Although these covered 70 countries, 81% of publications focused on only 12 countries (United States, United Kingdom, Australia, Canada, Mexico, Brazil, Chile, France, Spain, Denmark, New Zealand, and South Africa). Studies from these countries employed more robust quantitative methods and included most of the evaluations of policy development, implementation, and cost-effectiveness. Few publications reported on Africa (n = 12), Central and South Asia (n = 5), and the Middle East (n = 6) regions. Few also assessed public-private partnerships (PPPs, n = 31, 6%) compared to voluntary approaches by the private sector (n = 96, 20%), the public sector (n = 90, 19%), and mandatory approaches (n = 288, 60%). Most evaluations of PPPs reported on the same 2 partnerships. Only 50% of publications assessing policy effectiveness compared outcomes between population groups stratified by an equity characteristic, and this proportion has decreased over time. There are striking inequities in the origin, scope, and design of these studies, suggesting that research capacity and funding lies in the hands of a few expert teams worldwide. The small number of studies on PPPs questions the evidence base underlying the international push for PPPs to promote health. Policy evaluations should consider impacts on equity more consistently. This study was registered at PROSPERO as CRD42020170963.

Public health engagement in alcohol licensing in England and Scotland: the ExILEnS mixed-method, natural experiment evaluation.

Background: International systematic reviews suggest an association between alcohol availability and increased alcohol-related harms. Alcohol availability is regulated through separate locally administered licensing systems in England and Scotland, in which local public health teams have a statutory role. The system in Scotland includes a public health objective for licensing. Public health teams engage to varying degrees in licensing matters but no previous study has sought to objectively characterise and measure their activity, examine their effectiveness, or compare practices between Scotland and England. Aim: To critically assess the impact and mechanisms of impact of public health team engagement in alcohol premises licensing on alcohol-related harms in England and Scotland. Methods: We recruited 39 diverse public health teams in England (n = 27) and Scotland (n = 12). Public health teams more active in licensing were recruited first and then matched to lower-activity public health teams. Using structured interviews (n = 66), documentation analysis, and expert consultation, we developed and applied the Public Health Engagement In Alcohol Licensing (PHIAL) measure to quantify six-monthly activity levels from 2012 to 2019. Time series of PHIAL scores, and health and crime outcomes for each area, were analysed using multivariable negative binomial mixed-effects models to assess correlations between outcome and exposure, with 18-month average PHIAL score as the primary exposure metric. In-depth interviews (n = 53) and a workshop (n = 10) explored public health team approaches and potential mechanisms of impact of alcohol availability interventions with public health team members and licensing stakeholders (local authority licensing officers, managers and lawyers/clerks, police staff with a licensing remit, local elected representatives). Findings: Nineteen public health team activity types were assessed in six categories: (1) staffing; (2) reviewing and (3) responding to licence applications; (4) data usage; (5) influencing licensing stakeholders/policy; and (6) public involvement. Usage and intensity of activities and overall approaches varied within and between areas over time, including between Scotland and England. The latter variation could be explained by legal, structural and philosophical differences, including Scotland's public health objective. This objective was felt to legitimise public health considerations and the use of public health data within licensing. Quantitative analysis showed no clear evidence of association between level of public health team activity and the health or crime outcomes examined, using the primary exposure or other metrics (neither change in, nor cumulative, PHIAL scores). Qualitative data suggested that public health team input was valued by many licensing stakeholders, and that alcohol availability may lead to harms by affecting the accessibility, visibility and norms of alcohol consumption, but that the licensing systems have limited power to act in the interests of public health. Conclusions: This study provides no evidence that public health team engagement in local licensing matters was associated with measurable downstream reductions in crime or health harms, in the short term, or over a 7-year follow-up period. The extensive qualitative data suggest that public health team engagement is valued and appears to be slowly reorienting the licensing system to better address health (and other) harms, especially in Scotland, but this will take time. A rise in home drinking, alcohol deliveries, and the inherent inability of the licensing system to reduce - or in the case of online sales, to contain - availability, may explain the null findings and will continue to limit the potential of these licensing systems to address alcohol-related harms. Future work: Further analysis could consider the relative success of different public health team approaches in terms of changing alcohol availability and retailing. A key gap relates to the nature and impact of online availability on alcohol consumption, harms and inequalities, alongside development and study of relevant policy options. A national approach to licensing data and oversight would greatly facilitate future studies and public health input to licensing. Limitations: Our interview data and therefore PHIAL scores may be limited by recall bias where documentary evidence of public health activity was not available, and by possible variability in grading of such activity, though steps were taken to minimise both. The analyses would have benefited from additional data on licensing policies and environmental changes that might have affected availability or harms in the study areas. Study registration: The study was registered with the Research Registry (researchregistry6162) on 26 October 2020. The study protocol was published in BMC Medical Research Methodology on 6 November 2018. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/129/11.

Research finds that when alcohol is more easily available, because more places sell alcohol or have longer opening hours, people tend to drink more and harms tend to increase. In England and Scotland, 'Licensing Committees' in local governments have power over which venues are given a licence to sell alcohol legally. They make decisions based on local policy and on licensing goals set out in law. Licensing laws are slightly different in both nations, and health representatives are often involved in trying to influence local licensing decisions and policies, to reduce alcohol-related harms. We aimed to find out what public health teams have done to influence alcohol licensing and whether their actions have affected alcohol-related harms. We recruited 39 public health teams (Scotland: 12; England: 27) and measured how active they were on licensing matters. We gathered detailed information (from interviews and papers) about their actions from 2012 to 2019, and asked them and others involved in licensing (including police, and local authority licensing teams and lawyers) about how their efforts might make a difference to harms. We gathered local data on alcohol-related health harms and crimes during 2009­19. We analysed whether any changes in these harms were related to the level of public health team activity, and explored differences between Scotland and England. Public health teams across Scotland and England took varied approaches to engaging in alcohol licensing, and their work was often welcomed by others working in the licensing system. However, we found no clear relationship between the level of licensing-related activity that public health teams engaged in and the levels of alcohol-related health harms or crime. This may be because their actions make only a modest difference to licensing decisions, or because it may take longer than the study period for them to have a sizeable impact. Reducing alcohol-related harms through licensing may require strengthening national licensing laws and the powers of public health teams, including by addressing online sales and home deliveries.

Health effects of neighborhood demolition and housing improvement: a prospective controlled study of 2 natural experiments in urban renewal.

OBJECTIVES: We took advantage of a 2-intervention natural experiment to investigate the impacts of neighborhood demolition and housing improvement on adult residents' mental and physical health. METHODS: We identified a longitudinal cohort (n = 1041, including intervention and control participants) by matching participants in 2 randomly sampled cross-sectional surveys conducted in 2006 and 2008 in 14 disadvantaged neighborhoods of Glasgow, United Kingdom. We measured residents' self-reported health with Medical Outcomes Study Short Form Health Survey version 2 mean scores. RESULTS: After adjustment for potential confounders and baseline health, mean mental and physical health scores for residents living in partly demolished neighborhoods were similar to the control group (mental health, b = 2.49; 95% confidence interval [CI] = -1.25, 6.23; P = .185; physical health, b = -0.24; 95% CI = -2.96, 2.48; P = .859). Mean mental health scores for residents experiencing housing improvement were higher than in the control group (b = 2.41; 95% CI = 0.03, 4.80; P = .047); physical health scores were similar between groups (b = -0.66; 95% CI = -2.57, 1.25; P = .486). CONCLUSIONS: Our findings suggest that housing improvement may lead to small, short-term mental health benefits. Physical deterioration and demolition of neighborhoods do not appear to adversely affect residents' health.