"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study.

BACKGROUND: The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector. METHODS: As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021. FINDINGS: Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience. CONCLUSIONS: While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

Community empowerment and mental wellbeing: longitudinal findings from a survey of people actively involved in the big local place-based initiative in England.

BACKGROUND: Community empowerment initiatives are receiving increased interest as ways of improving health and reducing health inequalities. PURPOSE: Longitudinally examine associations between collective control, social-cohesion and mental wellbeing amongst participants in the Big Local community empowerment initiative across 150 disadvantaged areas of England. METHODS: As part of the independent Communities in Control study, we analysed nested cohort survey data on mental wellbeing (Short Warwick Edinburgh Mental Wellbeing Scale-SWEMWBS) and perceptions of collective control and social-cohesion. Data were obtained in 2016, 2018 and 2020 for 217 residents involved in the 150 Big Local areas in England. Adjusted linear mixed effect models were utilized to examine changes in SWEMWBS over the three waves. Subgroup analysis by gender and educational level was conducted. RESULTS: There was a significant 1.46 (0.14, 2.77) unit increase in mental wellbeing score at wave 2 (2018) but not in wave 3 (2020) (0.06 [-1.41, 1.53]). Across all waves, collective control was associated with a significantly higher mental wellbeing score (3.36 [1.51, 5.21]) as was social cohesion (1.09 [0.19, 2.00]). Higher educated participants (1.99 [0.14, 3.84]) and men (2.41 [0.55, 4.28]) experienced significant increases in mental wellbeing in 2018, but lower educated participants and women did not. CONCLUSION: Collective control and social cohesion are associated with better mental wellbeing amongst residents engaged with the Big Local initiative. These health benefits were greater amongst men and participants from higher educational backgrounds. This suggests that additional care must be taken in future interventions to ensure that benefits are distributed equally.

Collective control, social cohesion and health and well-being: baseline survey results from the communities in control study in England.

BACKGROUND: Area-based initiatives (ABIs) are receiving renewed interest as a part of the 'place-based public health' approaches to reducing health inequalities. PURPOSE: Examine associations between collective control, social cohesion and health amongst residents involved in the Big Local (BL) ABI. METHODS: Survey data on general health, mental well-being, perceptions of individual and collective control and social cohesion was obtained in 2016 for 1600 residents involved in the 150 BL ABI areas in England, and 862 responded-a response rate of >50%. Adjusted mean differences and adjusted odds ratios (ORs) were calculated using random effect linear and generalized estimating equation models. Subgroup analysis by gender and educational level was conducted. RESULTS: Mental well-being was positively associated with collective control (mean difference: 3.06 units, 1.23-4.90) and some measures of social cohesion ('people in the area are willing to help each other' [mean difference: 1.77 units, 0.75-2.78]). General health was positively associated with other measures of social cohesion (area-belonging [OR: 4.25, 2.26-7.97]). CONCLUSIONS: Collective control and some aspects of social cohesion were positively associated with better mental well-being and self-rated health amongst residents involved with BL. These positive associations were often greater amongst women and participants with a lower education. Increasing the collective control residents have in ABIs could improve the health effects of ABIs.

Examining the effectiveness of place-based interventions to improve public health and reduce health inequalities: an umbrella review.

BACKGROUND: Locally delivered, place-based public health interventions are receiving increasing attention as a way of improving health and reducing inequalities. However, there is limited evidence on their effectiveness. This umbrella review synthesises systematic review evidence of the health and health inequalities impacts of locally delivered place-based interventions across three elements of place and health: the physical, social, and economic environments. METHODS: Systematic review methodology was used to identify recent published systematic reviews of the effectiveness of place-based interventions on health and health inequalities (PROGRESS+) in high-income countries. Nine databases were searched from 1st January 2008 to 1st March 2020. The quality of the included articles was determined using the Revised Assessment of Multiple Systematic Reviews tool (R-AMSTAR). RESULTS: Thirteen systematic reviews were identified - reporting 51 unique primary studies. Fifty of these studies reported on interventions that changed the physical environment and one reported on changes to the economic environment. Only one primary study reported cost-effectiveness data. No reviews were identified that assessed the impact of social interventions. Given heterogeneity and quality issues, we found tentative evidence that the provision of housing/home modifications, improving the public realm, parks and playgrounds, supermarkets, transport, cycle lanes, walking routes, and outdoor gyms - can all have positive impacts on health outcomes - particularly physical activity. However, as no studies reported an assessment of variation in PROGRESS+ factors, the effect of these interventions on health inequalities remains unclear. CONCLUSIONS: Place-based interventions can be effective at improving physical health, health behaviours and social determinants of health outcomes. High agentic interventions indicate greater improvements for those living in greater proximity to the intervention, which may suggest that in order for interventions to reduce inequalities, they should be implemented at a scale commensurate with the level of disadvantage. Future research needs to ensure equity data is collected, as this is severely lacking and impeding progress on identifying interventions that are effective in reducing health inequalities. TRIAL REGISTRATION: PROSPERO CRD42019158309.

Pathways to mental health improvement in a community-led area-based empowerment initiative: evidence from the Big Local 'Communities in Control' study, England.

BACKGROUND: Area-based initiatives that include a focus on community empowerment are increasingly being seen as potentially an important way of improving health and reducing inequalities. However, there is little empirical evidence on the pathways between communities having more control and health outcomes. PURPOSE: To identify pathways to health improvement in a community-led area-based community empowerment initiative. METHODS: Longitudinal data on mental health, community control, area belonging, satisfaction, social cohesion and safety were collected over two time points, 6 months apart from 48 participants engaged in the Big Local programme, England. Qualitative comparative analysis (QCA) was used to explore pathways to health improvement. RESULTS: There was no clear single pathway that led to mental health improvement but positive changes in 'neighbourhood belonging' featured in 4/5 health improvement configurations. Further, where respondents experienced no improvement in key social participation/control factors, they experienced no health improvement. CONCLUSION: This study demonstrates a potential pathway between an improvement in 'neighbourhood belonging' and improved mental health outcomes in a community empowerment initiative. Increasing neighbourhood belonging could be a key target for mental health improvement interventions.

Equal North: how can we reduce health inequalities in the North of England? A prioritization exercise with researchers, policymakers and practitioners.

BACKGROUND: The Equal North network was developed to take forward the implications of the Due North report of the Independent Inquiry into Health Equity. The aim of this exercise was to identify how to reduce health inequalities in the north of England. METHODS: Workshops (15 groups) and a Delphi survey (3 rounds, 368 members) were used to consult expert opinion and achieve consensus. Round 1 answered open questions around priorities for action; Round 2 used a 5-point Likert scale to rate items; Round 3 responses were re-rated alongside a median response to each item. In total, 10 workshops were conducted after the Delphi survey to triangulate the data. RESULTS: In Round 1, responses from 253 participants generated 39 items used in Round 2 (rated by 144 participants). Results from Round 3 (76 participants) indicate that poverty/implications of austerity (4.87 m, IQR 0) remained the priority issue, with long-term unemployment (4.8 m, IQR 0) and mental health (4.7 m, IQR 1) second and third priorities. Workshop 3 did not diverge from findings in Round 1. CONCLUSIONS: Practice professionals and academics agreed that reducing health inequalities in the North of England requires prioritizing research that tackles structural determinants concerning poverty, the implications of austerity measures and unemployment.

Inequalities in mental health and well-being in a time of austerity: Follow-up findings from the Stockton-on-Tees cohort study.

In response to the 2007/8 financial crisis and the subsequent 'Great Recession', the UK government pursued a policy of austerity, characterised by public spending cuts and reductions in working-age welfare benefits. This paper reports on a case study of the effects of this policy on local inequalities in mental health and wellbeing in the local authority of Stockton-on-Tees in the North East of England, an area with very high spatial and socio-economic inequalities. Follow-up findings from a prospective cohort study of the gap in mental health and wellbeing between the most and least deprived neighbourhoods of Stockton-on-Tees is presented. It is the first quantitative study to use primary data to intensively and longitudinally explore local inequalities in mental health and wellbeing during austerity and it also examines any changes in the underpinning social and behavioural determinants of health. Using a stratified random sampling technique, the data was analysed using linear mixed effects model (LMM) that explored any changes in the gap in mental health and wellbeing between people from the most and least deprived areas, alongside any changes in the material, psychosocial and behavioural determinants. The main findings are that the significant gap in mental health between the two areas remained constant over the 18-month study period, whilst there were no changes in the underlying determinants. These results may reflect our relatively short follow-up period or the fact that the cohort sample were older than the general population and pensioners in the UK have largely been protected from austerity. The study therefore potentially provides further empirical evidence to support assertions that social safety nets matter - particularly in times of economic upheaval.

Geographical inequalities in health in a time of austerity: Baseline findings from the Stockton-on-Tees cohort study.

Stockton-on-Tees has the highest geographical inequalities in health in England with the life expectancy at birth gap between the most and deprived neighbourhoods standing at over 17 years for men and 11 years for women. In this study, we provide the first detailed empirical examination of this geographical health divide by: estimating the gap in physical and general health (as measured by EQ. 5D, EQ. 5D-VAS and SF8PCS) between the most and least deprived areas; using a novel statistical technique to examining the causal role of compositional and contextual factors and their interaction; and doing so in a time of economic recession and austerity. Using a stratified random sampling technique, individual-level survey data was combined with secondary data sources and analysed using multi-level models with 95% confidence intervals obtained from nonparametric bootstrapping. The main findings indicate that there is a significant gap in health between the two areas, and that compositional level material factors, contextual factors and their interaction appear to be the major explanations of this gap. Contrary to the dominant policy discourse in this area, individual behavioural and psychosocial factors did not make a significant contribution towards explaining health inequalities in the study area. The findings are discussed in relation to geographical theories of health inequalities and the context of austerity.

Inequalities in mental health and well-being in a time of austerity: Baseline findings from the Stockton-on-Tees cohort study.

Since 2010, the UK has pursued a policy of austerity characterised by public spending cuts and welfare changes. There has been speculation - but little actual research - about the effects of this policy on health inequalities. This paper reports on a case study of local health inequalities in the local authority of Stockton-on-Tees in the North East of England, an area characterised by high spatial and socio-economic inequalities. The paper presents baseline findings from a prospective cohort study of inequalities in mental health and mental wellbeing between the most and least deprived areas of Stockton-on-Tees. This is the first quantitative study to explore local mental health inequalities during the current period of austerity and the first UK study to empirically examine the relative contributions of material, psychosocial and behavioural determinants in explaining the gap. Using a stratified random sampling technique, the data was analysed using multi-level models that explore the gap in mental health and wellbeing between people from the most and least deprived areas of the local authority, and the relative contributions of material, psychosocial and behavioural factors to this gap. The main findings indicate that there is a significant gap in mental health between the two areas, and that material and psychosocial factors appear to underpin this gap. The findings are discussed in relation to the context of the continuing programme of welfare changes and public spending cuts in the UK.

Food for thought: an ethnographic study of negotiating ill health and food insecurity in a UK foodbank.

Emergency foodbanks have become an increasingly prominent and controversial feature of austerity in Europe and the USA. In the UK, foodbanks have been called a 'public health emergency'. Despite this, there has been no UK research examining the health of foodbank users. Through an ethnographic study, this paper is the first to explore the health and health perceptions of foodbank users via a case study of Stockton-on-Tees in the North East of England, UK during a period of welfare reform and austerity. Participant observation, field notes and interviews with foodbank users and volunteers were conducted over a seventeen month period (November 2013 to March 2015) inside a Trussell Trust foodbank. Foodbank users were almost exclusively of working age, both men and women, with and without dependent children. All were on very low incomes - from welfare benefits or insecure, poorly paid employment. Many had pre-existing health problems which were exacerbated by their poverty and food insecurity. The latter meant although foodbank users were well aware of the importance and constitution of a healthy diet, they were usually unable to achieve this for financial reasons - constantly having to negotiate their food insecurity. More typically they had to access poor quality, readily available, filling, processed foods. Foodbank users are facing the everyday reality of health inequalities at a time of ongoing austerity in the UK.

Better health at work? An evaluation of the effects and cost-benefits of a structured workplace health improvement programme in reducing sickness absence.

BACKGROUND: This paper presents the results of an evaluation of the Better Health at Work Award-a structured regional workplace health programme which combined changes to the work environment with lifestyle interventions. METHODS: Baseline and follow-up data on sickness-absence rates and programme costs were collected retrospectively via a web survey of all participating organizations. Changes over time were calculated using 95% confidence intervals of the mean, supplemented by hypothesis testing using a t-test. The indicative cost-benefits of the intervention were also calculated. RESULTS: Participation was associated with a mean reduction in sickness absence of 0.26-1.6 days per employee per year depending on the length and level of participation in the programme. The estimated cost for the programme was £3 per sickness-absence day saved. CONCLUSIONS: These results suggest that the Better Health at Work Award could be a cost-effective way of improving health and reducing sickness absence particularly in the public sector. However, controlled evaluations of future interventions are needed.

A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults.

BACKGROUND: Socioeconomic inequalities in obesity are well established in high-income countries. There is a lack of evidence of the types of intervention that are effective in reducing these inequalities among adults. OBJECTIVES: To systematically review studies of the effectiveness of individual, community and societal interventions in reducing socio-economic inequalities in obesity among adults. METHODS: Nine electronic databases were searched from start date to October 2012 along with website and grey literature searches. The review examined the best available international evidence (both experimental and observational) of interventions at an individual, community and societal level that might reduce inequalities in obesity among adults (aged 18 years or over) in any setting and country. Studies were included if they reported a body fatness-related outcome and if they included a measure of socio-economic status. Data extraction and quality appraisal were conducted using established mechanisms and narrative synthesis was conducted. RESULTS: The 'best available' international evidence was provided by 20 studies. At the individual level, there was evidence of the effectiveness of primary care delivered tailored weight loss programmes among deprived groups. Community based behavioural weight loss interventions and community diet clubs (including workplace ones) also had some evidence of effectiveness-at least in the short term. Societal level evaluations were few, low quality and inconclusive. Further, there was little evidence of long term effectiveness, and few studies of men or outside the USA. However, there was no evidence to suggest that interventions increase inequalities. CONCLUSIONS: The best available international evidence suggests that some individual and community-based interventions may be effective in reducing socio-economic inequalities in obesity among adults in the short term. Further research is required particularly of more complex, multi-faceted and societal-level interventions.

Prospective pilot evaluation of the effectiveness and cost-utility of a 'health first' case management service for long-term Incapacity Benefit recipients.

BACKGROUND: In line with the NICE guidance, an NHS-commissioned case management intervention was provided for individuals receiving Incapacity Benefit payments for ≥3 years in the North East of England. The intervention aimed to improve the health of the participants. METHODS: A total of 131 participants receiving the intervention were compared over 9 months with a (non-equivalent) comparison group of 229 receiving Incapacity Benefit payments and usual care. Health was measured using EQ-5D, EQ-VAS, SF-8, HADS and the Nordic Musculoskeletal questionnaire. Socio-demographic and health behaviour data were also collected. Fixed-effects linear models with correlated errors were used to compare health changes between groups over time. A preliminary cost-utility analysis was also conducted. RESULTS: The comparison group measures of health were stable over time. Starting from comparatively poor initial levels, case-management group generic (EQ5D, EQ-VAS) and mental health (HADS-A, HADS-D and SF8-MCS) measures improved within 6 months to similar levels found in the comparison group. Musculoskeletal (Nordic 2) and health behaviours did not improve. Tentative estimates of cost-utility suggest an intervention cost in the region of £16 700-£23 500 per QALY. CONCLUSIONS: Case management interventions may improve the health of Incapacity Benefit recipients. Further research is required to help confirm these pilot findings.

Applying qualitative comparative analysis (QCA) in public health: a case study of a health improvement service for long-term incapacity benefit recipients.

BACKGROUND: This paper explores the value of qualitative comparative analysis (QCA) in public health research using the example of a pilot case management intervention for long-term incapacity benefit recipients. It uses QCA to examine how the 'health improvement' effects of the intervention varied by individual and service characteristics. METHODS: Data for 131 participants receiving the intervention were collected over 9 months. Health improvement was measured using the EuroQual Visual Analogue Scale. Socio-demographic, health behaviour data were also collected. Data on service use was obtained from the provider's client records. Crisp set QCA was conducted to identify which individual and service characteristics were most likely to produce a health benefit after participation in the intervention. RESULTS: Health improvement was most likely amongst younger participants, men aged over 50 and those with an occupational history of skilled manual work or higher and less likely amongst older women, those with a musculoskeletal condition and those with semi- or un-skilled backgrounds. Service characteristics had no impact. CONCLUSIONS: The QCA identified potential causal pathways for health improvement from the intervention with important potential implications for health inequalities. QCA should be considered as a viable and practical method in the public health evaluation tool box.

'It was just nice to be able to talk to somebody': long-term incapacity benefit recipients' experiences of a case management intervention.

BACKGROUND: This paper provides important contextual and service implementation data by exploring participant experiences of a pilot case management intervention for long-term incapacity benefit (IB) recipients. METHODS: Service experiences were assessed via a postal questionnaire and semi-structured qualitative telephone interviews. Data from 77 service user questionnaires and 20 semi-structured qualitative interviews were obtained. Questionnaire data were analysed using SPSS and telephone interviews were transcribed, thematically coded and analysed using NVivo. RESULTS: Respondents were generally positive about their experience of the intervention and particularly the benefit gained from the personal support that case managers provided. However, they also made suggestions about how the service could be delivered more effectively particularly in terms of the duration of the treatments and increasing the level of face-to-face support. CONCLUSIONS: Case management approaches may offer a supportive environment in which the health needs of those in the long-term receipt of IB can be addressed.

Defying deprivation: a cross-sectional analysis of area level health resilience in England.

Previous research has found evidence that some economically deprived areas in England exhibit 'health resilience' in terms of lower than expected mortality rates. Consistent with earlier research we analysed area 'resilience' for parliamentary constituencies and our work extends previous research by including measures of morbidity. Standardised Morbidity Ratios (SMRs) of self-reported general health, limiting long-term illness, emergency hospital admissions, and CHD hospital admissions were derived from the 2001 UK Census and 2001 Hospital Episodes Statistics, and combined into a Composite Morbidity Index (CMI). Area variation in the CMI was compared with previous findings about mortality rates. Multiple Correspondence Analysis (MCA) was used to test the associations between area level 'health resilience' and ethnic composition, residential mobility, employment type, housing tenure, and an indicator of social cohesion. Nine areas were 'resilient' in terms of morbidity. Only four areas of England exhibited 'health resilience' in terms of both mortality and morbidity. MCA revealed that there may be several factors associated with greater 'health resilience'.

Real world reviews: a beginner's guide to undertaking systematic reviews of public health policy interventions.

BACKGROUND: The systematic review is becoming an increasingly popular and established research method in public health. Obtaining systematic review skills are therefore becoming a common requirement for most public health researchers and practitioners. However, most researchers still remain apprehensive about conducting their first systematic review. This is often because an 'ideal' type of systematic review is promoted in the methods literature. METHODS: This brief guide is intended to help dispel these concerns by providing an accessible overview of a 'real' approach to conducting systematic reviews. The guide draws upon an extensive practical experience of conducting various types of systematic reviews of complex social interventions. RESULTS: The paper discusses what a systematic review is and how definitions vary. It describes the stages of a review in simple terms. It then draws on case study reviews to reflect on five key practical aspects of the conduct of the method, outlining debates and potential ways to make the method shorter and smarter--enhancing the speed of production of systematic reviews and reducing labour intensity while still maintaining high methodological standards. CONCLUSION: There are clear advantages in conducting the high quality pragmatic reviews that this guide has described: (1) time and labour resources are saved; (2) it enables reviewers to inform or respond to developments in policy and practice in a timelier manner; and (3) it encourages researchers to conduct systematic reviews before embarking on primary research. Well-conducted systematic reviews remain a valuable part of the public health methodological tool box.

A labour of Sisyphus? Public policy and health inequalities research from the Black and Acheson Reports to the Marmot Review.

OBJECTIVES: To explore similarities and differences in policy content and the political context of the three main English government reports on health inequalities: the Black Report (1980), the Acheson Enquiry (1998), and the Marmot Review (2010). METHODS: Thematic policy and context analysis of the Black Report (1980), the Acheson Enquiry (1998), and the Marmot Review (2010) in terms of: (i) underpinning theoretical principles; (ii) policy recommendations; (iii) the political contexts in which each was released; and (iv) their actual or potential influence on research and policy. RESULTS: There were great similarities and very few differences in terms of both the theoretical principles guiding the recommendations of these reports and the focus of the recommendations themselves. However, there were clear differences in terms of the political contexts of each report, as well as their subsequent impacts on research and policy. CONCLUSION: The paper calls into question the progress of health inequalities research, the use of evidence and of the links between research, politics and policy.