Clusters of Activity-Related Social and Physical Home Environmental Factors and Their Association With Children's Home-Based Physical Activity and Sitting.

PURPOSE: Understanding which physical activity (PA) and sedentary behavior correlates cluster in children is important, particularly in the home, where children spend significant time. Therefore, this study aimed to assess clustering of physical and social activity-related factors at home, and whether these clusters are related to home-based sitting and PA in children. A secondary aim was to explore whether the clusters were associated with child, parent, and family characteristics. METHODS: Altogether, 235 children (55% girls, mean age = 10.2 [0.7] y) and their parents took part. Physical (eg, PA and electronic media equipment, house and garden size, layout) and social (eg, activity preferences, priorities, parental rules) home environmental factors were obtained via the HomeSPACE-II audit and self-report, respectively. Principal component analysis was used to identify clusters of physical and social environmental factors. Backward regression analysis and partial correlations were used to examine relationships between clusters, children's device-measured home-based activity behaviors, and background characteristics. RESULTS: The findings show that physical and social environment activity-related factors at home cluster. The clusters were associated with several background characteristics, with socioeconomic factors appearing to be particularly influential. The clusters were also associated with home-based activity behaviors in the hypothesized directions. CONCLUSION: Interventions which target clusters of social and physical factors at home, especially among low-socioeconomic status families, are warranted.

Agricultural Injury Surveillance Using a Regional Trauma Registry.

BACKGROUND: The burden of traumatic injury among workers in agriculture is substantial. Surveillance can inform injury prevention efforts to reduce farmworkers' risk. We posited that the regional trauma registry can provide surveillance for agricultural injury requiring trauma-center care. METHODS: The Northeast Texas regional trauma registry was queried for patients injured in agricultural settings during 2016-2019 occurring in the 23,580 square mile study area subdivided into 219 US Census Zip Code Tract Area (ZCTA). Population at risk was estimated from the 2017 Census of Agriculture. Kuldorff's SaTScan identified case hot spots. A multivariable, geographically weighted regression model was fit for cases/1000 workers. RESULTS: In total, 273 cases occurred, (mean 68 cases per year [95% confidence interval 55.1-80.9]) among 96 ZCTA. The mean injury rate was 3.9 (95% confidence interval 3.4-4.3) cases per 1000 farmworkers. Animals and farm machinery were the most common injury mechanisms, 52.0% and 20.9%, respectively. Trauma ZCTA demonstrated more farms (median 170 versus 95.5, P < 0.001), greater farm acreage (53,900 acres versus 32,800, P = 0.004), and higher median total product sales ($6.5 million versus $3.9 million, P < 0.001). Six hot spots were identified with relative risks from 2.85 to 5.31. The multivariable model of cases/1000 workers demonstrated significant associations with workers per ZCTA (a mean ß-coefficient of 0.004 with P values <0.05 in 145 of 219 [66.5%] ZCTA) and percent rural population (ß = -6.62, P values <0.05 in 76.1% of ZCTA). CONCLUSIONS: Regional trauma registry data, combined with census data and spatial analyses, can identify actionable geographic areas of high agriculture-related injury risk.

COVID-19 infection risk amongst 14,104 vaccinated care home residents: a national observational longitudinal cohort study in Wales, UK, December 2020-March 2021.

BACKGROUND: vaccinations for COVID-19 have been prioritised for older people living in care homes. However, vaccination trials included limited numbers of older people. AIM: we aimed to study infection rates of SARS-CoV-2 for older care home residents following vaccination and identify factors associated with increased risk of infection. STUDY DESIGN AND SETTING: we conducted an observational data-linkage study including 14,104 vaccinated older care home residents in Wales (UK) using anonymised electronic health records and administrative data. METHODS: we used Cox proportional hazards models to estimate hazard ratios (HRs) for the risk of testing positive for SARS-CoV-2 infection following vaccination, after landmark times of either 7 or 21 days post-vaccination. We adjusted HRs for age, sex, frailty, prior SARS-CoV-2 infections and vaccination type. RESULTS: we observed a small proportion of care home residents with positive polymerase chain reaction (tests following vaccination 1.05% (N = 148), with 90% of infections occurring within 28 days. For the 7-day landmark analysis we found a reduced risk of SARS-CoV-2 infection for vaccinated individuals who had a previous infection; HR (95% confidence interval) 0.54 (0.30, 0.95). For the 21-day landmark analysis, we observed high HRs for individuals with low and intermediate frailty compared with those without; 4.59 (1.23, 17.12) and 4.85 (1.68, 14.04), respectively. CONCLUSIONS: increased risk of infection after 21 days was associated with frailty. We found most infections occurred within 28 days of vaccination, suggesting extra precautions to reduce transmission risk should be taken in this time frame.

Annual risk of falls resulting in emergency department and hospital attendances for older people: an observational study of 781,081 individuals living in Wales (United Kingdom) including deprivation, frailty and dementia diagnoses between 2010 and 2020.

BACKGROUND: falls are common in older people, but associations between falls, dementia and frailty are relatively unknown. The impact of the COVID-19 pandemic on falls admissions has not been studied. AIM: to investigate the impact of dementia, frailty, deprivation, previous falls and the differences between years for falls resulting in an emergency department (ED) or hospital admission. STUDY DESIGN: longitudinal cross-sectional observational study. SETTING: older people (aged 65+) resident in Wales between 1 January 2010 and 31 December 2020. METHODS: we created a binary (yes/no) indicator for a fall resulting in an attendance to an ED, hospital or both, per person, per year. We analysed the outcomes using multilevel logistic and multinomial models. RESULTS: we analysed a total of 5,141,244 person years of data from 781,081 individuals. Fall admission rates were highest in 2012 (4.27%) and lowest in 2020 (4.27%). We found an increased odds ratio (OR [95% confidence interval]) of a fall admission for age (1.05 [1.05, 1.05] per year of age), people with dementia (2.03 [2.00, 2.06]) and people who had a previous fall (2.55 [2.51, 2.60]). Compared with fit individuals, those with frailty had ORs of 1.60 [1.58, 1.62], 2.24 [2.21, 2.28] and 2.94 [2.89, 3.00] for mild, moderate and severe frailty respectively. Reduced odds were observed for males (0.73 [0.73, 0.74]) and less deprived areas; most deprived compared with least OR 0.75 [0.74, 0.76]. CONCLUSIONS: falls prevention should be targeted to those at highest risk, and investigations into the reduction in admissions in 2020 is warranted.

Do home adaptation interventions help to reduce emergency fall admissions? A national longitudinal data-linkage study of 657,536 older adults living in Wales (UK) between 2010 and 2017.

BACKGROUND: falls are common in older people, but evidence for the effectiveness of preventative home adaptations is limited. AIM: determine whether a national home adaptation service, Care&Repair Cymru (C&RC), identified individuals at risk of falls occurring at home and reduced the likelihood of falls. STUDY DESIGN: retrospective longitudinal controlled non-randomised intervention cohort study. SETTING: our cohort consisted of 657,536 individuals aged 60+ living in Wales (UK) between 1 January 2010 and 31 December 2017. About 123,729 individuals received a home adaptation service. METHODS: we created a dataset with up to 41 quarterly observations per person. For each quarter, we observed if a fall occurred at home that resulted in either an emergency department or an emergency hospital admission. We analysed the data using multilevel logistic regression. RESULTS: compared to the control group, C&RC clients had higher odds of falling, with an odds ratio (OR [95% confidence interval]) of 1.93 [1.87, 2.00]. Falls odds was higher for females (1.44 [1.42, 1.46]), older age (1.07 [1.07, 1.07]), increased frailty (mild 1.57 [1.55, 1.60], moderate 2.31 [2.26, 2.35], severe 3.05 [2.96, 3.13]), and deprivation (most deprived compared to least: 1.16 [1.13, 1.19]). Client fall odds decreased post-intervention; OR 0.97 [0.96, 0.97] per quarter. Regional variation existed for falls (5.8%), with most variation at the individual level (31.3%). CONCLUSIONS: C&RC identified people more likely to have an emergency fall admission occurring at home, and their service reduced the odds of falling post-intervention. Service provisioning should meet the needs of an individual and need varies by personal and regional circumstance.

The impact of dementia, frailty and care home characteristics on SARS-CoV-2 incidence in a national cohort of Welsh care home residents during a period of high community prevalence.

BACKGROUND: dementia may increase care home residents' risk of COVID-19, but there is a lack of evidence on this effect and on interactions with individual and care home-level factors. METHODS: we created a national cross-sectional retrospective cohort of care home residents in Wales for 1 September to 31 December 2020. Risk factors were analysed using multi-level logistic regression to model the likelihood of SARS-CoV-2 infection and mortality. RESULTS: the cohort included 9,571 individuals in 673 homes. Dementia was diagnosed in 5,647 individuals (59%); 1,488 (15.5%) individuals tested positive for SARS-CoV-2. We estimated the effects of age, dementia, frailty, care home size, proportion of residents with dementia, nursing and dementia services, communal space and region. The final model included the proportion of residents with dementia (OR for positive test 4.54 (95% CIs 1.55-13.27) where 75% of residents had dementia compared to no residents with dementia) and frailty (OR 1.29 (95% CIs 1.05-1.59) for severe frailty compared with no frailty). Analysis suggested 76% of the variation was due to setting rather than individual factors. Additional analysis suggested severe frailty and proportion of residents with dementia was associated with all-cause mortality, as was dementia diagnosis. Mortality analyses were challenging to interpret. DISCUSSION: whilst individual frailty increased the risk of COVID-19 infection, dementia was a risk factor at care home but not individual level. These findings suggest whole-setting interventions, particularly in homes with high proportions of residents with dementia and including those with low/no individual risk factors may reduce the impact of COVID-19.

Intensity of COVID-19 in care homes following hospital discharge in the early stages of the UK epidemic.

BACKGROUND: defining features of the COVID-19 pandemic in many countries were the tragic extent to which care home residents were affected and the difficulty in preventing the introduction and subsequent spread of infection. Management of risk in care homes requires good evidence on the most important transmission pathways. One hypothesised route at the start of the pandemic, prior to widespread testing, was the transfer of patients from hospitals that were experiencing high levels of nosocomial events. METHODS: we tested the hypothesis that hospital discharge events increased the intensity of care home cases using a national individually linked health record cohort in Wales, UK. We monitored 186,772 hospital discharge events over the period from March to July 2020, tracking individuals to 923 care homes and recording the daily case rate in the homes populated by 15,772 residents. We estimated the risk of an increase in case rates following exposure to a hospital discharge using multi-level hierarchical logistic regression and a novel stochastic Hawkes process outbreak model. FINDINGS: in regression analysis, after adjusting for care home size, we found no significant association between hospital discharge and subsequent increases in care home case numbers (odds ratio: 0.99, 95% CI: 0.82, 1.90). Risk factors for increased cases included care home size, care home resident density and provision of nursing care. Using our outbreak model, we found a significant effect of hospital discharge on the subsequent intensity of cases. However, the effect was small and considerably less than the effect of care home size, suggesting the highest risk of introduction came from interaction with the community. We estimated that approximately 1.8% of hospital discharged patients may have been infected. INTERPRETATION: there is growing evidence in the UK that the risk of transfer of COVID-19 from the high-risk hospital setting to the high-risk care home setting during the early stages of the pandemic was relatively small. Although access to testing was limited to initial symptomatic cases in each care home at this time, our results suggest that reduced numbers of discharges, selection of patients and action taken within care homes following transfer all may have contributed to the mitigation. The precise key transmission routes from the community remain to be quantified.

The impact of COVID-19 on adjusted mortality risk in care homes for older adults in Wales, UK: a retrospective population-based cohort study for mortality in 2016-2020.

BACKGROUND: mortality in care homes has had a prominent focus during the COVID-19 outbreak. Care homes are particularly vulnerable to the spread of infectious diseases, which may lead to increased mortality risk. Multiple and interconnected challenges face the care home sector in the prevention and management of outbreaks of COVID-19, including adequate supply of personal protective equipment, staff shortages and insufficient or lack of timely COVID-19 testing. AIM: to analyse the mortality of older care home residents in Wales during COVID-19 lockdown and compare this across the population of Wales and the previous 4 years. STUDY DESIGN AND SETTING: we used anonymised electronic health records and administrative data from the secure anonymised information linkage databank to create a cross-sectional cohort study. We anonymously linked data for Welsh residents to mortality data up to the 14th June 2020. METHODS: we calculated survival curves and adjusted Cox proportional hazards models to estimate hazard ratios (HRs) for the risk of mortality. We adjusted HRs for age, gender, social economic status and prior health conditions. RESULTS: survival curves show an increased proportion of deaths between 23rd March and 14th June 2020 in care homes for older people, with an adjusted HR of 1.72 (1.55, 1.90) compared with 2016. Compared with the general population in 2016-2019, adjusted care home mortality HRs for older adults rose from 2.15 (2.11, 2.20) in 2016-2019 to 2.94 (2.81, 3.08) in 2020. CONCLUSIONS: the survival curves and increased HRs show a significantly increased risk of death in the 2020 study periods.

Are individual and social factors specific to the home associated with children's behaviour and physical environment at home.

This study used linear regression analyses to investigate the influence of parent-reported home-specific social and individual factors on: (i) 235 children's home-based objectively measured overall sitting time, breaks in sitting, and PA, and; (ii) the home physical environment via an audit. Parental importance assigned to active play for children was positively associated with PA equipment (accessibility and availability), as well as light physical activity (LPA) and sitting breaks on both weekdays and weekend days. Parental preference for being active at home and limits on screen-time were associated with less household media equipment and portable media equipment, respectively. Greater parental importance placed on playing electronic games/using computers for fun was associated with less LPA and more sitting on weekdays. Further, children who preferred being sedentary sat more and engaged in less moderate-vigorous physical activity (MVPA) on weekdays. Parental and child preferences and priorities, as well as parental rules for activity at home, were associated with children's home-based sitting and PA, especially on weekdays. Such factors were also associated with the physical environment in the expected directions. The findings suggest interventions need to target social and individual factors, alongside adapting the physical environment to create homes more promotive of physical activity.

Do home modifications reduce care home admissions for older people? A matched control evaluation of the Care & Repair Cymru service in Wales.

BACKGROUND: home advice and modification interventions aim to promote independent living for those living in the community, but quantitative evidence of their effectiveness is limited. AIM: assess the risk of care home admissions for people with different frailty levels receiving home advice and modification interventions against a control group who do not. STUDY DESIGN AND SETTING: matched control evaluation using linked longitudinal data from the Secure Anonymised Information Linkage (SAIL) Databank, comprising people aged 60-95, registered with a SAIL contributing general practice. The intervention group received the Care & Repair Cymru (C & RC) service, a home advice and modification service available to residents in Wales. METHODS: frailty, age and gender were used in propensity score matching to assess the Hazard Ratio (HR) of care home admissions within a 1-, 3- and 5-year period for the intervention group (N = 93,863) compared to a matched control group (N = 93,863). Kaplan-Meier curves were used to investigate time to a care home admission. RESULTS: the intervention group had an increased risk of a care home admission at 1-, 3- and 5-years [HR (95%CI)] for those classified as fit [1-year: 2.02 (1.73, 2.36), 3-years: 1.87 (1.72, 2.04), 5-years: 1.99 (1.86, 2.13)] and mildly frail [1-year: 1.25 (1.09, 1.42), 3-years: 1.25 (1.17, 1.34), 5-years: 1.30 (1.23, 1.38)], but a reduced risk of care home admission for moderately [1-year: 0.66 (0.58, 0.75), 3-years: 0.75 (0.70, 0.80), 5-years: 0.83 (0.78, 0.88)] and severely frail individuals [1-year: 0.44 (0.37, 0.54), 3-years: 0.54 (0.49, 0.60), 5-years: 0.60(0.55, 0.66)]. CONCLUSIONS: HRs indicated that the C & RC service helped to prevent care home admissions for moderately and severely frail individuals. The HRs generally increased with follow-up duration.

GIS-modelled built-environment exposures reflecting daily mobility for applications in child health research.

BACKGROUND: Inaccurately modelled environmental exposures may have important implications for evidence-based policy targeting health promoting or hazardous facilities. Travel routes modelled using GIS generally use shortest network distances or Euclidean buffers to represent journeys with corresponding built-environment exposures calculated along these routes. These methods, however, are an unreliable proxy for calculating child built-environment exposures as child route choice is more complex than shortest network routes. METHODS: We hypothesised that a GIS model informed by characteristics of the built-environment known to influence child route choice could be developed to more accurately model exposures. Using GPS-derived walking commutes to and from school we used logistic regression models to highlight built-environment features important in child route choice (e.g. road type, traffic light count). We then recalculated walking commute routes using a weighted network to incorporate built-environment features. Multilevel regression analyses were used to validate exposure predictions to the retail food environment along the different routing methods. RESULTS: Children chose routes with more traffic lights and residential roads compared to the modelled shortest network routes. Compared to standard shortest network routes, the GPS-informed weighted network enabled GIS-based walking commutes to be derived with more than three times greater accuracy (38%) for the route to school and more than 12 times greater accuracy (92%) for the route home. CONCLUSIONS: This research advocates using weighted GIS networks to accurately reflect child walking journeys to school. The improved accuracy in route modelling has in turn improved estimates of children's exposures to potentially hazardous features in the environment. Further research is needed to explore if the built-environment features are important internationally. Route and corresponding exposure estimates can be scaled to the population level which will contribute to a better understanding of built-environment exposures on child health and contribute to mobility-based child health policy.

External validation of the electronic Frailty Index using the population of Wales within the Secure Anonymised Information Linkage Databank.

BACKGROUND: frailty has major implications for health and social care services internationally. The development, validation and national implementation of the electronic Frailty Index (eFI) using routine primary care data has enabled change in the care of older people living with frailty in England. AIMS: to externally validate the eFI in Wales and assess new frailty-related outcomes. STUDY DESIGN AND SETTING: retrospective cohort study using the Secure Anonymised Information Linkage (SAIL) Databank, comprising 469,000 people aged 65-95, registered with a SAIL contributing general practice on 1 January 2010. METHODS: four categories (fit; mild; moderate and severe) of frailty were constructed using recognised cut points from the eFI. We calculated adjusted hazard ratios (HRs) from Cox regression models for validation of existing outcomes: 1-, 3- and 5-year mortality, hospitalisation, and care home admission for validation. We also analysed, as novel outcomes, 1-year mortality following hospitalisation and frailty transition times. RESULTS: HR trends for the validation outcomes in SAIL followed the original results from ResearchOne and THIN databases. Relative to the fit category, adjusted HRs in SAIL (95% CI) for 1-year mortality following hospitalisation were 1.05 (95% CI 1.03-1.08) for mild frailty, 1.24 (95% CI 1.21-1.28) for moderate frailty and 1.51 (95% CI 1.45-1.57) for severe frailty. The median time (lower and upper quartile) between frailty categories was 2,165 days (lower and upper quartiles: 1,510 and 2,831) from fit to mild, 1,155 days (lower and upper quartiles: 756 and 1,610) from mild to moderate and 898 days (lower and upper quartiles: 584 and 1,275) from moderate to severe. CONCLUSIONS: further validation of the eFI showed robust predictive validity and utility for new outcomes.

Targeting epigenetic nuclear reprogramming in aggregated cloned equine embryos.

Epigenetic perturbations during the reprogramming process have been described as the primary cause of the low efficiency of somatic cell nuclear transfer (SCNT). In this study, we tested three strategies targeting nuclear reprogramming to investigate effects on equine SCNT. First, we evaluated the effect of treating somatic cells with chetomin, a fungal secondary metabolite reported to inhibit the trimethylation on histone 3 lysine 9 (H3K9 me3). Second, caffeine was added to the culture medium during the enucleation of oocytes and before activation of reconstructed embryos as a protein phosphatase inhibitor to improve nuclear reprogramming. Third, we tested the effects of the histone deacetylase inhibitor trichostatin A (TSA) added during both activation and early embryo culture. Although none of these treatments significantly improved the developmental rates of the invitro aggregated cloned equine embryos, the first equine cloned foal born in Australia was produced with somatic cells treated with chetomin. The present study describes the use of chetomin, caffeine and TSA for the first time in horses, serving as a starting point for the establishment of future protocols to target epigenetic reprogramming for improving the efficiency of equine cloning. Cloning is an expensive and inefficient process, but has gained particular interest in the equine industry. In this study we explored different strategies to improve cloning efficiency and produced the first cloned foal born in Australia. Our data serve as a starting point for the establishment of future protocols for improving equine cloning efficiency.

The effect of physiological state, milk production traits and environmental conditions on milk fat globule size in cow's milk.

This research was carried out to quantify the effects of a range of variables on milk fat globule (MFG) size for a herd of Holstein-Friesian cows managed through an automatic milking system with year-round calving. We hypothesised that the overall variation in average MFG size observed between individual animals of the same herd cannot sufficiently be explained by the magnitude of the effects of variables that could be manipulated on-farm. Hence, we aimed to conduct an extensive analysis of possible determinants of MFG size, including physiological characteristics (parity, days in milk, days pregnant, weight, age, rumination minutes, somatic cell count) and milk production traits (number of milkings, milk yield, fat yield, protein and fat content, fat-protein ratio) on the individual animal level; and environmental conditions (diet, weather, season) for the whole herd. Our results show that when analysed in isolation, many of the studied variables have a detectable effect on MFG size. However, analysis of their additive effects identified days in milk, parity and milk yield as the most important variables. In accordance with our hypothesis, the estimated effects of these variables, calculated using a multiple variable linear mixed model, do not sufficiently explain the overall variation between cows, ranging from 2.70 to 5.69 µm in average MFG size. We further show that environmental variables, such as sampling day (across seasons) or the proportion of pasture and silage in the diet, have limited effects on MFG size and that physiological differences outweigh the effects of milk production traits and environmental conditions. This presents further evidence that the selection of individual animals is more important than the adjustment of on-farm variables to control MFG size.

Children and young people's body mass index measures derived from routine data sources: A national data linkage study in Wales.

BACKGROUND: Routine monitoring of Body Mass Index (BMI) in general practice, and via national surveillance programmes, is essential for the identification, prevention, and management of unhealthy childhood weight. We examined and compared the presence and representativeness of children and young people's (CYPs) BMI recorded in two routinely collected administrative datasets: general practice electronic health records (GP-BMI) and the Child Measurement Programme for Wales (CMP-BMI), which measures height and weight in 4-5-year-old school children. We also assessed the feasibility of combining GP-BMI and CMP-BMI data for longitudinal analyses. METHODS: We accessed de-identified population-level GP-BMI data for calendar years 2011 to 2019 for 246,817 CYP, and CMP-BMI measures for 222,772 CYP, held within the Secure Anonymised Information Linkage Databank. We examined the proportion of CYP in Wales with at least one GP-BMI record, its distribution by child socio-demographic characteristics, and trends over time. We compared GP-BMI and CMP-BMI distributions. We quantified the proportion of children with a CMP-BMI measure and a follow-up GP-BMI recorded at an older age and explored the representativeness of these measures. RESULTS: We identified a GP-BMI record in 246,817 (41%) CYP, present in a higher proportion of females (54.2%), infants (20.7%) and adolescents. There was no difference in the deprivation profile of those with a GP-BMI measurement. 31,521 CYP with a CMP-BMI had at least one follow-up GP-BMI; those with a CMP-BMI considered underweight or very overweight were 87% and 70% more likely to have at least one follow-up GP-BMI record respectively compared to those with a healthy weight, as were males and CYP living in the most deprived areas of Wales. CONCLUSIONS: Records of childhood weight status extracted from general practice are not representative of the population and are biased with respect to weight status. Linkage of information from the national programme to GP records has the potential to enhance discussions around healthy weight at the point of care but does not provide a representative estimate of population level weight trajectories, essential to provide insights into factors determining a healthy weight gain across the early life course. A second CMP measurement is required in Wales.

The use of Enhanced Vegetation Index for assessing access to different types of green space in epidemiological studies.

BACKGROUND: Exposure to green space can protect against poor health through a variety of mechanisms. However, there is heterogeneity in methodological approaches to exposure assessments which makes creating effective policy recommendations challenging. OBJECTIVE: Critically evaluate the use of a satellite-derived exposure metric, the Enhanced Vegetation Index (EVI), for assessing access to different types of green space in epidemiological studies. METHODS: We used Landsat 5-8 (30 m resolution) to calculate average EVI for a 300 m radius surrounding 1.4 million households in Wales, UK for 2018. We calculated two additional measures using topographic vector data to represent access to green spaces within 300 m of household locations. The two topographic vector-based measures were total green space area stratified by type and average private garden size. We used linear regression models to test whether EVI could discriminate between publicly accessible and private green space and Pearson correlation to test associations between EVI and green space types. RESULTS: Mean EVI for a 300 m radius surrounding households in Wales was 0.28 (IQR = 0.12). Total green space area and average private garden size were significantly positively associated with corresponding EVI measures (ß = < 0.0001, 95% CI: 0.0000, 0.0000; ß = 0.0001, 95% CI: 0.0001, 0.0001 respectively). In urban areas, as average garden size increases by 1 m2, EVI increases by 0.0002. Therefore, in urban areas, to see a 0.1 unit increase in EVI index score, garden size would need to increase by 500 m2. The very small ß values represent no 'measurable real-world' associations. When stratified by type, we observed no strong associations between greenspace and EVI. IMPACT: It is a widely implemented assumption in epidiological studies that an increase in EVI is equivalent to an increase in greenness and/or green space. We used linear regression models to test associations between EVI and potential sources of green reflectance at a neighbourhood level using satellite imagery from 2018. We compared EVI measures with a 'gold standard' vector-based dataset that defines publicly accessible and private green spaces. We found that EVI should be interpreted with care as a greater EVI score does not necessarily mean greater access to publicly available green spaces in the hyperlocal environment.

How does the local area deprivation influence life chances for children in poverty in Wales: A record linkage cohort study.

Objectives: Children growing up in poverty are less likely to achieve in school and more likely to experience mental health problems. This study examined factors in the local area that can help a child overcome the negative impact of poverty. Design: A longitudinal record linkage retrospective cohort study. Participants: This study included 159,131 children who lived in Wales and completed their age 16 exams (Key Stage 4 (KS4)) between 2009 and 2016. Free School Meal (FSM) provision was used as an indicator of household-level deprivation. Area-level deprivation was measured using the Welsh Index of Multiple Deprivation (WIMD) 2011. An encrypted unique Anonymous Linking Field was used to link the children with their health- and educational records. Outcome measures: The outcome variable 'Profile to Leave Poverty' (PLP) was constructed based on successful completion of age 16 exams, no mental health condition, no substance and alcohol misuse records in routine data. Logistic regression with stepwise model selection was used to investigate the association between local area deprivation and the outcome variable. Results: 22% of children on FSM achieved PLP compared to 54.9% of non-FSM children. FSM Children from least deprived areas were significantly more likely to achieve PLP (adjusted odds ratio (aOR) - 2.20 (1.93, 2.51)) than FSM children from most deprived areas. FSM children, living in areas with higher community safety, higher relative income, higher access to services, were more likely to achieve PLP than their peers. Conclusion: The findings indicate that community-level improvements such as increasing safety, connectivity and employment might help in child's education attainment, mental health and reduce risk taking behaviours.

Can routine data be used to estimate the mental health service use of children and young people living on Gypsy and Traveller sites in Wales? A feasibility study.

INTRODUCTION: Gypsies and Travellers have poorer physical and mental health than the general population, but little is known about mental health service use by Gypsy and Traveller children and young people. Finding this group in routine electronic health data is challenging, due to limited recording of ethnicity. We assessed the feasibility of using geographical markers combined with linked routine datasets to estimate the mental health service use of children and young people living on Traveller sites. METHODS: Welsh Government supplied a list of Traveller site postcodes included in Caravan Counts between 2012 and 2020. Using spatial filtering with data from the Adolescent Mental Health Data Platform (ADP) at Swansea University's SAIL Databank, we created a cohort of Traveller site residents aged 11-25 years old, 2010-2019. ADP algorithms were used to describe health service use, and to estimate incidence and prevalence of common mental disorders (CMD) and self-harm. RESULTS: Our study found a subgroup of young Gypsies and Travellers (n = 802). We found no significant differences between our cohort and the general population for rates of CMD or self-harm. The rate of non-attendance for psychiatric outpatient follow-up appointments was significantly higher in our cohort. Rates were higher (but not statistically significant) among Gypsies and Travellers for measures suggesting less well-managed care, including emergency department attendance and prescribed CMD medication without follow-up. The small size of the cohort resulted in imprecise estimates with wide confidence intervals, compared with those for the general population. CONCLUSIONS: Gypsies and Travellers are under-represented in routine health datasets, even using geographical markers, which find only those resident in authorised traveller sites. Routine data is increasingly relied upon for needs assessment and service planning, which has policy and practice implications for this underserved group. To address health inequalities effort is required to ensure that health datasets accurately capture ethnicity.