Strengthening the equity focus of applied public health research: introducing the FOR EQUITY platform.

OBJECTIVES: Much applied health research pays insufficient attention to potential unequal impacts across social groups or is typically focused on a single dimension (e.g. socio-economic status), rarely considering the intersecting social processes driving inequalities (e.g. racism, sexism, classism). All health research needs a strong intersectional equity focus in order to inform action to reduce health inequalities as well as improve population health. STUDY DESIGN: Focus On Research and Equity (FOR EQUITY) is a new Web-based platform aiming to strengthen the intersectional equity focus of applied health research. METHODS: The platform was developed in collaboration with members of the public, practitioners and researchers working internationally. The development involved a systematic review of academic and grey literature, a series of workshops and user testing. RESULTS: FOR EQUITY encompasses (1) a Health Inequalities Assessment Tool, with an intersectional perspective on inequalities; (2) a FOR EQUITY Guidance Inventory providing access to a range of international research toolkits and guidance; and (3) a FOR EQUITY Library including case studies illustrating how researchers have attempted to integrate an equity lens into the research process and more general resources on health inequalities. CONCLUSION: FOR EQUITY can support researchers to strengthen the equity lens in their studies to make research evidence more relevant for action to reduce social and health inequalities. However, a single focus on toolkits is unlikely to sufficiently address the barriers to embedding equity in research. A mainstreaming strategy to transform the very roots of the 'institution of research' is required.

Strategies for knowledge exchange for action to address place-based determinants of health inequalities: an umbrella review.

BACKGROUND: Place-based health inequalities persist despite decades of academics and other stakeholders generating ideas and evidence on how to reduce them. This may in part reflect a failure in effective knowledge exchange (KE). We aim to understand what KE strategies are effective in supporting actions on place-based determinants and the barriers and facilitators to this KE. METHODS: An umbrella review was undertaken to identify relevant KE strategies. Systematic reviews were identified by searching academic databases (Medline, Embase, Scopus, Web of Science) and handsearching. Synthesis involved charting and thematic analysis. RESULTS: Fourteen systematic reviews were included comprising 105 unique, relevant studies. Four approaches to KE were identified: improving access to knowledge, collaborative approaches, participatory models and KE as part of advocacy. While barriers and facilitators were reported, KE approaches were rarely evaluated for their effectiveness. CONCLUSIONS: Based on these four approaches, our review produced a framework, which may support planning of future KE strategies. The findings also suggest the importance of attending to political context, including the ways in which this may impede a more upstream place-based focus in favour of behavioural interventions and the extent that researchers are willing to engage with politicized agendas.

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.

System resilience and neighbourhood action on social determinants of health inequalities: an English Case Study.

AIMS: This article seeks to make the case for a new approach to understanding and nurturing resilience as a foundation for effective place-based co-produced local action on social and health inequalities. METHODS: A narrative review of literature on community resilience from a public health perspective was conducted and a new concept of neighbourhood system resilience was developed. This then shaped the development of a practical programme of action research implemented in nine socio-economically disadvantaged neighbourhoods in North West England between 2014 and 2019. This Neighbourhood Resilience Programme (NRP) was evaluated using a mixed-method design comprising: (1) a longitudinal household survey, conducted in each of the Neighbourhoods For Learning (NFLs) and in nine comparator areas in two waves (2015/2016 and 2018/2019) and completed in each phase by approximately 3000 households; (2) reflexive journals kept by the academic team; and (3) semi-structured interviews on perceptions about the impacts of the programme with 41 participants in 2019. RESULTS: A difference-in-difference analysis of household survey data showed a statistically significant increase of 7.5% (95% confidence interval (CI), 1.6 to 13.5) in the percentage of residents reporting that they felt able to influence local decision-making in the NFLs relative to the residents in comparator areas, but no effect attributable to the NRP in other evaluative measures. The analysis of participant interviews identified beneficial impacts of the NRP in five resilience domains: social connectivity, cultural coherence, local decision-making, economic activity, and the local environment. CONCLUSION: Our findings support the need for a shift away from interventions that seek solely to enhance the resilience of lay communities to interventions that recognise resilience as a whole systems phenomenon. Systemic approaches to resilience can provide the underpinning foundation for effective co-produced local action on social and health inequalities, but they require intensive relational work by all participating system players.

Quantifying the shrinkage of laryngeal laser excisions: a case control study.

OBJECTIVE: Heat from transoral laser microsurgery can cause tissue shrinkage, impacting the surgical margin. This study aimed to compare shrinkage between cold steel and carbon dioxide laser resections of laryngeal lesions. METHODS: A European Laryngological Society type II resection was performed on 10 mm 'lesions' marked on both the true and false folds of fresh-frozen human larynxes; specifically, laser resection was performed on the right side and cold steel resection on the left side. RESULTS: Twenty-eight larynxes were included. Tissue shrinkage was significantly higher in laser resection (35-45 per cent) compared to cold steel resection (8-14 per cent) (p < 0.0001). In most cases, there was no significant difference in shrinkage between true and false fold sites. CONCLUSION: This study demonstrates that specimen shrinkage is significantly higher in laser resections. This shrinkage will affect the size of the surgical margin; surgeons and pathologists should be aware of this when considering positive and close margins.

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.

Description of a novel technique for creation of a custom-made prosthesis to aid vocalisation following laryngectomy.

There are various options to restore phonation after laryngectomy; one option involves using tracheo-oesophageal voice by placing a speaking valve through the tracheo-oesophageal wall. Some patients struggle to obtain good fixation of an adhesive base plate to the skin; this can result in air leakage and poor voice. We describe a technique using a custom-made prosthesis to provide a better base plate for fixation of the heat and moisture exchange cassette. This technique involves making an impression of the anterior neck around the laryngectomy stoma to create an anatomically fitted prosthesis, which accurately fills the void around the stoma. The custom-made prosthesis provides a more individualised fit compared to a standard base plate, helping improve vocalisation and communication.

"I realised it weren't about spending the money. It's about doing something together:" the role of money in a community empowerment initiative and the implications for health and wellbeing.

Community initiatives aiming to reduce health inequalities are increasingly common in health policy. Though diverse many such initiatives aim to support residents of disadvantaged places to exercise greater collective control over decisions/actions that affect their lives - which research suggests is an important determinant of health - and some seek to achieve this by giving residents control over a budget. Informed by theoretical work in which community capabilities for collective control are conceptualised as different forms of power, and applying a relational lens, this paper presents findings on the potential role of money as a mechanism to enhance these capabilities from an on-going evaluation of a major place-based initiative being implemented in 150 neighbourhoods across England:The Big Local (BL). The research involved semi-structured interviews with 116 diverse stakeholders, including residents and participant observation in a diverse sample of 10 BL areas. We took a thematic constant comparative approach to the analysis of data from across the sites. The findings suggest that the money enabled the development of capabilities for collective control in these communities primarily by enhancing connectivity amongst residents and with external stakeholders. However, residents had to engage in significant 'relational work' to achieve these benefits and tensions around the money could hinder communities' 'power to act'. Greater social connectivity has been shown to directly affect individual and population health by increasing social cohesion and reducing loneliness. Additionally, supporting enhanced collective control of residents in these disadvantaged communities has the potential to improve population health and reduce health inequalities.

Leisure centre entrance charges and physical activity participation in England.

Reducing or eliminating the cost to the public of using leisure facilities is one tool that local authorities have available to reduce inequalities in physical activity (PA). There is limited evidence about the effect of leisure entrance charges and their impact on participation. This study aimed to ascertain how facility pricing influenced the decisions people made about how to pay and what to pay for and how, in turn, these decisions impacted on participation for different groups. A total of 83 members of the public living in 4 local authorities in the North West of England were involved in focus groups or individual interviews. The results show that cost was a key factor which influenced PA participation in low income neighbourhoods. In practise, however, the majority of service users navigated the range of prices or payment options to find one that was suitable rather than simply reporting whether leisure was affordable or not. Whilst pre-paid options (e.g. direct debit memberships) encouraged participation, entrance charges incurred each time an individual participated had a negative impact on frequency but were a convenient way of paying for occasional use or for people who were unable to afford a pre-paid option. Free access also helped people who could not afford pre-paid membership to exercise regularly as well as incentivizing non-users to try activities. The research concluded that policies that include components of free access and offer more flexible payment options are most likely to contribute to reducing inequalities in PA.

The impact of free access to swimming pools on children's participation in swimming. A comparative regression discontinuity study.

OBJECTIVE: Investigating the extent to which providing children with free swimming access during school holidays increased participation in swimming and whether this effect differed according to the socioeconomic deprivation of the neighbourhoods in which children lived. SETTING: A highly disadvantaged local authority (LA) in North West England. INTERVENTION: Provision of children with free swimming during the summer holidays. OUTCOME MEASURES: Number of children swimming, and the number of swims, per 100 population in 2014. DESIGN: Comparative regression discontinuity investigating the extent to which participation rates amongst children aged 5-15 were greater in the intervention LA compared to a similar control LA. We estimated the differential effect of the intervention across five groups, defined by quintiles of area deprivation. RESULTS: Free swimming during the summer holidays was associated with an additional 6% of children swimming (95% CI: 4-9%) and an additional 33 swims per 100 children per year (95% CI: 21-44). The effects were greatest in areas with intermediate levels of deprivation (quintiles 3 and 4) within this deprived LA. CONCLUSION: Providing free facilities for children in disadvantaged areas is likely to increase swimming participation and may help reduce inequalities in physical activity.

Using local authority entrance charges to tackle inequalities in physical activity? A qualitative study of leisure and public health perspectives.

Background: Reducing or eliminating entrance charges for the public use of leisure facilities is one potential tool that local authorities (LA) have to reduce inequalities in physical activity (PA). Facility charges are likely to be a greater barrier to access for those who have lower incomes. Methods: Semi-structured 1-to-1 and group interviews were conducted with 33 leisure and public health professionals in seven LAs in north-west England. We investigated how approaches to pricing varied in these settings and rationales influencing decision making. Results: Welfare orientated (e.g. affordability) and commercial drivers (e.g. income generation) featured most prominently across areas. Pricing policies placed less direct focus on public health goals, although tackling inactivity was articulated as part of leisure's role more generally. Local targeting of free/concessionary offers was also defined and implemented differently. Decision makers described navigating competing pressures of providing services for the public 'good' yet remaining financially viable. Conclusion: Many LAs are reviewing the extent of subsidy for facilities or are considering whether to invest public health budgets in leisure. The findings offer evidence of how pricing decisions are made and the approaches adopted in practice as well as the conflicting priorities for decision makers within an austerity context.

Management of pinna haematoma study (MaPHaeS): A multicentre retrospective observational study.

OBJECTIVES: To assess current variation in the management of pinna haematoma (PH) and its effect on outcomes. DESIGN: Multicentre retrospective observational record-based study. SETTING: Eleven hospitals around the UK. PARTICIPANTS: Eighty-three patients above the age of 16 with PH. OUTCOME MEASURES: The primary outcome measure was recurrence rate of PH over a 6-month period post-treatment, assessed by treatment type (scalpel incision vs needle aspiration). Secondary outcome measures assessed the impact of other factors on recurrence, infection and cosmetic complications of PH over a period of 6 months. RESULTS: After adjusting for confounding factors, involvement of the whole ear, and management within an operating theatre were associated with a lower rate of recurrence of pinna haematoma. The drainage technique, suspected aetiology, choice of post-drainage management, grade and specialty of practitioner performing drainage, the use of antibiotic cover and hospital admission did not affect the rate of haematoma recurrence, infection or cosmetic complications. CONCLUSIONS: Where possible PH should be drained in an operating theatre. Multicentre randomized controlled trials are required to further investigate the impact of drainage technique and post-drainage management on outcome.

Reducing cardiovascular responses to laryngoscopy and tracheal intubation: a comparison of equipotent doses of tramadol, nalbuphine and pethidine, with placebo.

The stress response to tracheal intubation may be obtunded by opioids given with induction of anesthesia. Tramadol is an opioid acting on mu-receptors and the monoaminergic pain modulating systems. This study examined vasomotor responses to tracheal intubation after equipotent doses of tramadol, nalbuphine and pethidine (3.0, 0.3 mg/kg(-1), and 1.5 mg/kg(-1), respectively), and placebo, given prior to induction of anesthesia in 118 healthy patients. Premedication and induction of anesthesia were standardized. Recordings of HR and SAP were made prior and subsequent to induction of anesthesia, and at 1, 3, 5 and 7 minutes after tracheal intubation. Prior to laryngoscopy and intubation, HR increased in all groups (p < or = 01, all comparisons), but least so after nalbuphine, whilst SAP remained unchanged after placebo, tramadol and pethidine, but fell after nalbuphine (p < 0.025). Maximum increases in HR (p < or = 0.005, all comparisons) and SAP (p < or = 0.02, all comparisons) occurred one minute after intubation. Maximum HR after placebo (108 SD 15 bpm), tramadol (107 SD 20 bpm), pethidine (113 SD 16 bpm) and nalbuphine (110 SD 26 bpm) was similar; with placebo HR remained faster than baseline until the seventh minute but had returned to baseline by the fifth minute with the opioids. Maximum SAP with tramadol (151 SD 26 mmHg) was similar to that with placebo (157 SD 20 mmHg), but was greater than after pethidine (136 SD 27 mmHg; p < 0.05) and nalbuphine (135 SD 19 mmHg; p < 0.02). With each test drug SAP returned to baseline by the third minute. It is concluded that, in these doses, 1) tramadol does not attenuate the chronotropic nor the inotropic response to tracheal intubation, and 2) pethidine and nalbuphine reduce only the inotropic response to airway instrumentation.

Enteroviral infections in primary immunodeficiency (PID): a survey of morbidity and mortality.

We have explored the natural history of enteroviral infection in patients with primary antibody deficiency by surveying both published and unpublished case reports before the new anti-enteroviral drug, pleconaril, was available. Many different enteroviruses were involved, Echovirus 11 being the most common. The central nervous system was nearly always involved, with evidence of systemic involvement of muscle and/or liver and/or joints in about 40% of patients. Neurological symptoms and signs varied with minor or no changes in the cerebro-spinal fluid. There was high morbidity and mortality; a third of polio cases (usually vaccine related), and nearly half of non-polio infected patients died; about 40% of survivors of the initial illness had long-term neurological symptoms. Prophylactic immunoglobulin therapy did not prevent infection but these patients were on lower doses as compared to current recommendations. Our data provides a useful background for assessing the efficacy of new anti-viral treatment in this condition.

Universal maternal screening for neonatal group B streptococcal disease.

Group B streptococcal infection is a leading cause of neonatal morbidity and mortality in the developed world. Data obtained in our region suggest that the incidence in the UK may be higher than previously reported, and together with the results of a pilot study indicate that preventive strategies based on maternal risk factors alone would prevent less than half the cases of neonatal disease.

Analgesia for adenotonsillectomy in children and young adults: a comparison of tramadol, pethidine and nalbuphine.

A prospective, double-blind, randomized, controlled study was undertaken to compare the perioperative analgesic and recovery characteristics of equipotent doses of tramadol, pethidine and nalbuphine (3.0 mg kg-1, 1.5 mg kg-1 and 0.3 mg kg-1 respectively) with placebo (saline 0.02 ml kg-1) given at induction of anaesthesia in 152 ASA 1 children and young adults undergoing tonsillo-adenoidectomy. Premedication (temazepam and diclofenac), induction and maintenance of anaesthesia (thiopentone, atracurium, nitrous oxide and isoflurane), with controlled ventilation, were standardized. Variables monitored were heart rate (HR) and systolic arterial pressure (SAP) during surgery, time to recovery of spontaneous respiration at the termination of anaesthesia and restlessness, time to awakening, sedation and emesis in the recovery unit. Increases in HR or SAP > 33% of baseline during surgery were treated with esmolol 2.0 mg kg-1 intravenously (i.v.) and restlessness during recovery was treated with the same opioid i.v. given with an aesthesia, or pethidine i.v. in the placebo group. With placebo, there was a high requirement for esmolol during surgery and for pethidine in the recovery ward. Tramadol did not reduce the rate of intra-operative treatment with esmolol, but reduced the tramadol requirement during recovery (P < 0.05). Pethidine and nalbuphine reduced the intra-operative esmolol requirement more significantly (P < 0.025 and P < 0.005 respectively) and the need for treatment during recovery with opioids (P < 0.005 each). The time to recovery of spontaneous respiration at the end of anaesthesia was only delayed by pethidine. Other recovery variables were similar, except that restlessness-pain scores were reduced by tramadol (P < 0.02), pethidine (P < 0.005) and nalbuphine (P < 0.005). These results suggest that pethidine 1.5 mg kg-1 and nalbuphine 0.3 mg kg-1 given with induction of anaesthesia provide better analgesia during and after tonsillo-adenoidectomy than does tramadol 3.0 mg kg-1. The delay to recovery of spontaneous respiration with pethidine suggests a greater safety profile of nalbuphine and tramadol.

The effects of tramadol on postoperative nausea, vomiting and headache after ENT surgery. A placebo-controlled comparison with equipotent doses of nalbuphine and pethidine.

BACKGROUND: Opioids given as adjuncts to balanced inhalational anaesthesia augment postoperative nausea and vomiting (PONV). Tramadol, equipotent to pethidine, does not depress respiration, but can cause an increase in blood pressure and headache via its monoaminergic actions. Nalbuphine, ten times as potent as pethidine, has a ceiling respiratory depressant and ceiling analgesic effect at > 0.3 mg.kg-1. We compared the effects of equipotent doses of tramadol and nalbuphine (3.0 and 0.3 mg.kg-1, respectively) given as analgesic with induction of anaesthesia on emesis during recovery from anaesthesia and on PONV and headache until 24 h after ENT surgery, using saline (0.2 ml.kg-1) and an equipotent dose of pethidine (1.5 mg.kg-1) as controls. METHOD: The study population (N = 281) comprised 4 comparable subgroups (N = 69 to 71 each). Anaesthetic medications were standardised. Emesis during recovery from anaesthesia and nausea, vomiting, retching, headache and administrations of antiemetic and analgesics until 24 h after surgery were recorded. RESULTS: Emesis and antiemetic requirements during recovery from anaesthesia were similar and infrequent in each group, as were the incidences of nausea alone (3 to 5%), vomiting alone (17 to 31%), and nausea with vomiting (10 to 22%) during the first 24 h after surgery. However, any complaint of PONV was least frequent in the saline and pethidine groups (32% and 37%, respectively) and most frequent in the tramadol and nalbuphine groups (49% and 52%, respectively; P < 0.05 versus saline, both comparisons; P = NS versus pethidine, both comparisons). The times to onset and severity of PONV were similar in each group, but patients given nalbuphine most frequently (P < 0.025) needed rescue antiemetic to treat PONV. Headache occurred with similar frequency in each group. CONCLUSION: It is concluded that tramadol, nalbuphine and pethidine have similar emetic effect in the doses and manner used, and that tramadol does not increase the incidence of post-operative headache when used as peroperative analgesic.

Diacetyl production mechanism by a strain of Lactococcus lactis spp. lactis bv. diacetylactis. Study of alpha-acetolactic acid extracellular accumulation under anaerobiosis.

Diacetyl production via alpha-acetolactic acid (ALA) extracellular decarboxylation in Lactococcus lactis spp. lactis bv. diacetylactis SD 933 cultures has been assessed under anaerobiosis both in batch and continuous fermentations at pH 5.5 and 8.0 by studying the effects of alpha-acetolactate decarboxylase (ADC) addition in the culture broth. This enzyme, favoring the formation of acetoin instead of diacetyl, was added extracellularly and did not disturb diacetyl production. Moreover, oxidation experiments on extracellular culture media did not reveal any increase in diacetyl amount caused by extracellular ALA oxidative decarboxylation. These observations confirm previous assertions concerning the mechanism and localization of diacetyl synthesis by the SD 933 strain.