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.

'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.

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.

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.

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.