Reducing challenging behaviours among children and adolescents with intellectual disabilities in community settings: a systematic review of interventions.

Background: Challenging behaviours are common among children and adolescents with intellectual disabilities. Such behaviours often result in poor quality of life outcomes such as physical injury, difficulties with relationships and community integration. Aim: This systematic review aimed to synthesise evidence from studies that assessed the effect of interventions used to reduce/manage challenging behaviour among children with intellectual disabilities in community settings. Methods: Studies published between January 2015 and January 2021 were sought from five electronic databases. The quality of studies was assessed, and a narrative synthesis was conducted. Results: A total of 11 studies were included which utilised various non-pharmacological interventions including multi-model interventions, microswitch technology, cognitive behavioural therapy, art, music and illustrated stories. Microswitch cluster technology was the most used intervention. Studies using pharmacological interventions were not retrieved. Results indicated that a person-centred planning approach was key to offering individualised treatment. Conclusions: The superiority of one intervention or a combination of interventions could not be determined from this review given the heterogeneity of studies. Future research is required to explore the use and effects of pharmacological interventions to compare outcomes and improve quality of care of children with intellectual disabilities.

Do poverty and wealth look the same the world over? A comparative study of 12 cities from five high-income countries using street images.

Urbanization and inequalities are two of the major policy themes of our time, intersecting in large cities where social and economic inequalities are particularly pronounced. Large scale street-level images are a source of city-wide visual information and allow for comparative analyses of multiple cities. Computer vision methods based on deep learning applied to street images have been shown to successfully measure inequalities in socioeconomic and environmental features, yet existing work has been within specific geographies and have not looked at how visual environments compare across different cities and countries. In this study, we aim to apply existing methods to understand whether, and to what extent, poor and wealthy groups live in visually similar neighborhoods across cities and countries. We present novel insights on similarity of neighborhoods using street-level images and deep learning methods. We analyzed 7.2 million images from 12 cities in five high-income countries, home to more than 85 million people: Auckland (New Zealand), Sydney (Australia), Toronto and Vancouver (Canada), Atlanta, Boston, Chicago, Los Angeles, New York, San Francisco, and Washington D.C. (United States of America), and London (United Kingdom). Visual features associated with neighborhood disadvantage are more distinct and unique to each city than those associated with affluence. For example, from what is visible from street images, high density poor neighborhoods located near the city center (e.g., in London) are visually distinct from poor suburban neighborhoods characterized by lower density and lower accessibility (e.g., in Atlanta). This suggests that differences between two cities is also driven by historical factors, policies, and local geography. Our results also have implications for image-based measures of inequality in cities especially when trained on data from cities that are visually distinct from target cities. We showed that these are more prone to errors for disadvantaged areas especially when transferring across cities, suggesting more attention needs to be paid to improving methods for capturing heterogeneity in poor environment across cities around the world. Supplementary Information: The online version contains supplementary material available at 10.1140/epjds/s13688-023-00394-6.

Changes in life expectancy and house prices in London from 2002 to 2019: hyper-resolution spatiotemporal analysis of death registration and real estate data.

Background: London has outperformed smaller towns and rural areas in terms of life expectancy increase. Our aim was to investigate life expectancy change at very-small-area level, and its relationship with house prices and their change. Methods: We performed a hyper-resolution spatiotemporal analysis from 2002 to 2019 for 4835 London Lower-layer Super Output Areas (LSOAs). We used population and death counts in a Bayesian hierarchical model to estimate age- and sex-specific death rates for each LSOA, converted to life expectancy at birth using life table methods. We used data from the Land Registry via the real estate website Rightmove (www.rightmove.co.uk), with information on property size, type and land tenure in a hierarchical model to estimate house prices at LSOA level. We used linear regressions to summarise how much life expectancy changed in relation to the combination of house prices in 2002 and their change from 2002 to 2019. We calculated the correlation between change in price and change in sociodemographic characteristics of the resident population of LSOAs and population turnover. Findings: In 134 (2.8%) of London's LSOAs for women and 32 (0.7%) for men, life expectancy may have declined from 2002 to 2019, with a posterior probability of a decline >80% in 41 (0.8%, women) and 14 (0.3%, men) LSOAs. The life expectancy increase in other LSOAs ranged from <2 years in 537 (11.1%) LSOAs for women and 214 (4.4%) for men to >10 years in 220 (4.6%) for women and 211 (4.4%) for men. The 2.5th-97.5th-percentile life expectancy difference across LSOAs increased from 11.1 (10.7-11.5) years in 2002 to 19.1 (18.4-19.7) years for women in 2019, and from 11.6 (11.3-12.0) years to 17.2 (16.7-17.8) years for men. In the 20% (men) and 30% (women) of LSOAs where house prices had been lowest in 2002, mainly in east and outer west London, life expectancy increased only in proportion to the rise in house prices. In contrast, in the 30% (men) and 60% (women) most expensive LSOAs in 2002, life expectancy increased solely independently of price change. Except for the 20% of LSOAs that had been most expensive in 2002, LSOAs with larger house price increases experienced larger growth in their population, especially among people of working ages (30-69 years), had a larger share of households who had not lived there in 2002, and improved their rankings in education, poverty and employment. Interpretation: Large gains in area life expectancy in London occurred either where house prices were already high, or in areas where house prices grew the most. In the latter group, the increases in life expectancy may be driven, in part, by changing population demographics. Funding: Wellcome Trust; UKRI (MRC); Imperial College London; National Institutes of Health Research.

Synthesizing the links between secure housing tenure and health for more equitable cities.

Millions of households in rich and poor countries alike are at risk of being unwilfully displaced from their homes or the land on which they live (i.e., lack secure tenure), and the urban poor are most vulnerable. Improving housing tenure security may be an intervention to improve housing and environmental conditions and reduce urban health inequalities. Building on stakeholder workshops and a narrative review of the literature, we developed a conceptual model that infers the mechanisms through which more secure housing tenure can improve housing, environmental quality, and health. Empirical studies show that more secure urban housing tenure can boost economic mobility, improve housing and environmental conditions including reduced exposure to pollution, create safer and more resourced communities, and improve physical and mental health. These links are shared across tenure renters and owners and different economic settings. Broader support is needed for context-appropriate policies and actions to improve tenure security as a catalyst for cultivating healthier homes and neighbourhoods and reducing urban health inequalities in cities.

Inequalities in excess premature mortality in England during the COVID-19 pandemic: a cross-sectional analysis of cumulative excess mortality by area deprivation and ethnicity.

OBJECTIVES: To examine magnitude of the impact of the COVID-19 pandemic on inequalities in premature mortality in England by deprivation and ethnicity. DESIGN: A statistical model to estimate increased mortality in population subgroups during the COVID-19 pandemic by comparing observed with expected mortality in each group based on trends over the previous 5 years. SETTING: Information on deaths registered in England since 2015 was used, including age, sex, area of residence and cause of death. Ethnicity was obtained from Hospital Episode Statistics records linked to death data. PARTICIPANTS: Population study of England, including all 569 824 deaths from all causes registered between 21 March 2020 and 26 February 2021. MAIN OUTCOME MEASURES: Excess mortality in each subgroup over and above the number expected based on trends in mortality in that group over the previous 5 years. RESULTS: The gradient in excess mortality by area deprivation was greater in the under 75s (the most deprived areas had 1.25 times as many deaths as expected, least deprived 1.14) than in all ages (most deprived had 1.24 times as many deaths as expected, least deprived 1.20). Among the black and Asian groups, all area deprivation quintiles had significantly larger excesses than white groups in the most deprived quintiles and there were no clear gradients across quintiles. Among the white group, only those in the most deprived quintile had more excess deaths than deaths directly involving COVID-19. CONCLUSION: The COVID-19 pandemic has widened inequalities in premature mortality by area deprivation. Among those under 75, the direct and indirect effects of the pandemic on deaths have disproportionately impacted ethnic minority groups irrespective of area deprivation, and the white group the most deprived areas. Statistics limited to deaths directly involving COVID-19 understate the pandemic's impact on inequalities by area deprivation and ethnic group at younger ages.

Life expectancy and risk of death in 6791 communities in England from 2002 to 2019: high-resolution spatiotemporal analysis of civil registration data.

BACKGROUND: High-resolution data for how mortality and longevity have changed in England, UK are scarce. We aimed to estimate trends from 2002 to 2019 in life expectancy and probabilities of death at different ages for all 6791 middle-layer super output areas (MSOAs) in England. METHODS: We performed a high-resolution spatiotemporal analysis of civil registration data from the UK Small Area Health Statistics Unit research database using de-identified data for all deaths in England from 2002 to 2019, with information on age, sex, and MSOA of residence, and population counts by age, sex, and MSOA. We used a Bayesian hierarchical model to obtain estimates of age-specific death rates by sharing information across age groups, MSOAs, and years. We used life table methods to calculate life expectancy at birth and probabilities of death in different ages by sex and MSOA. FINDINGS: In 2002-06 and 2006-10, all but a few (0-1%) MSOAs had a life expectancy increase for female and male sexes. In 2010-14, female life expectancy decreased in 351 (5·2%) of 6791 MSOAs. By 2014-19, the number of MSOAs with declining life expectancy was 1270 (18·7%) for women and 784 (11·5%) for men. The life expectancy increase from 2002 to 2019 was smaller in MSOAs where life expectancy had been lower in 2002 (mostly northern urban MSOAs), and larger in MSOAs where life expectancy had been higher in 2002 (mostly MSOAs in and around London). As a result of these trends, the gap between the first and 99th percentiles of MSOA life expectancy for women increased from 10·7 years (95% credible interval 10·4-10·9) in 2002 to reach 14·2 years (13·9-14·5) in 2019, and for men increased from 11·5 years (11·3-11·7) in 2002 to 13·6 years (13·4-13·9) in 2019. INTERPRETATION: In the decade before the COVID-19 pandemic, life expectancy declined in increasing numbers of communities in England. To ensure that this trend does not continue or worsen, there is a need for pro-equity economic and social policies, and greater investment in public health and health care throughout the entire country. FUNDING: Wellcome Trust, Imperial College London, Medical Research Council, Health Data Research UK, and National Institutes of Health Research.

Nowhere to Play: Available Open and Green Space in Greater London Schools.

Experiencing outdoor space, especially natural space, during childhood and adolescence has beneficial physical and mental health effects, including improved cognitive and motor skills and a lower risk of obesity. Since school-age children typically spend 35-40 hours per week at schools, we quantified their access to open (non-built-up) space and green space at schools in Greater London. We linked land use information from the UK Ordnance Survey with school characteristics from the Department for Education (DfE) for schools in Greater London. We estimated open space by isolating land and water features within school boundaries and, as a subset of open space, green space defined as open space covered by vegetation. We examined the relationship of both school open and green space with distance to Central London, whether the school was fee-paying, and the percentage of pupils eligible for free school meals (as a school-level indicator of socioeconomic status). Almost 400,000 pupils (30% of all pupils in London) attended schools with less than ten square metre per pupil of open space-the minimum recommended area by DfE-and 800,000 pupils attended schools with less than ten square metre per pupil of green space. Of the latter, 70% did not have any public parks in the immediate vicinity of their schools. School green space increased with distance from Central London. There was a weak association between the school-level socioeconomic indicator and the amount of open and green space. Fee-paying schools provided less open space compared to non-fee-paying schools in central parts of London, but the provision became comparable in suburban London. Many London schools do not provide enough open and green space. There is a need to ensure regular contact with green space through safeguarding school grounds from sales, financially supporting disadvantaged schools to increase their outdoor space and providing access to off-site facilities such as sharing outdoor space with other schools.

Health benefits from devolution in England: international lessons.

The Chancellor of the Exchequer's recent announcements to devolve decision making power from Whitehall to 30 English regions provide a challenge to use devolution to deliver more favourable health outcomes. However evaluation of devolved health models internationally is scarce, because it is rarely considered. Evidence from countries with long-standing experience of devolution finds that the best approaches are holistic, seeking fiscal freedoms to sustain the environment, promote health, well-being and citizen engagement. Overall, international outcomes are mixed, with some evidence of greater efficiency of care delivery but little hard evidence of better clinical outcomes or health status. Handling specialised services in a devolved health system is challenging. Regulation by national authorities is important to avoid gaming of the system by providers. Information from the devolved area is important in demonstrating equitable access. We present an evaluation framework and recommend that evaluation continues through governance of these deals during implementation.

Women Who Lead: Successes and Challenges of Five Health Leaders.

Women make up approximately 75% of the health workforce and yet their representation at higher levels of health leadership is limited. Untapped potential of women in health undermines the contribution they could make to effective leadership for health systems strengthening. Lived experiences of women leaders can help understand how to unlock this potential by identifying the challenges, highlighting enablers, and sharing successful strategies used to become effective health leaders. This article uses phenomenological inquiry to understand the subjective experiences of five influential women in their paths to health leadership. Interviews were conducted with these women and key messages were identified. A grounding theme-defined as the essential element for the subjective experience of leading as a woman in the health system-was revealed to be the women's "drive for equity." This drive motivated them to pursue a career in health and to break through perceived gender-related barriers. Three figural themes around how to practice effective health leadership to promote equity were identified: (1) challenging status quos and norms; (2) leading by listening and leveraging others' expertise to build a common vision for health; and (3) having social support early on to develop confidence and credibility. Stories from the individual women's experiences are presented. Finally, three recommendations are made for system-level mechanisms that could contribute to expanding the number of women leaders in health.

Excess winter deaths in Europe: a multi-country descriptive analysis.

BACKGROUND: Winter deaths are a known health and social care challenge for many countries. A previous international comparison showed significant differences in excess winter deaths across Europe in the 1990s, with the northern countries having lower excess winter mortality than those in southern Europe. METHODS: The Excess Winter Deaths Index (EWDI) is the ratio of deaths in the winter period (December to March) compared with deaths in the non-winter period. Data from the Eurostat database and national registries were used to calculate the EWDI for 31 countries in Europe across the time period 2002/2003 to 2010/2011. RESULTS: National EWDI values show heterogeneity, with a broad pattern of increasing EWDI values from northern to southern Europe and increasing mean winter temperature (r(2) = 0.50, P > 0.0001). Malta, Portugal, Spain, Cyprus and Belgium all had an EWDI that was statistically significantly higher than the average EWDI for the other 30 European countries. There was no clear association between country-level EWDI and the level of inter-annual variability in winter temperature across Europe. DISCUSSION: This article demonstrates the differences in EWDI that exist between European countries with implications for both research and policy. Many deaths may be avoidable as environmental, social and personal factors are known to contribute to winter mortality. We now need to work to better understand the causes of inter-country differences.

A model of successful ageing in British populations.

BACKGROUND: European populations are ageing rapidly yet, although, it is widely recognized that some individuals age more successfully than others, an agreed concept of successful ageing remains elusive. We sought to develop a model of successful ageing in a British population, which combines the subjective and objective elements of successful ageing that have previously been proposed. METHODS: Structural equation modelling was used to provide a model of successful ageing, defined in subjective and objective terms. The data comprised 15,000 subjects aged ≥ 50 years in England, recruited to the Health and Lifestyle Surveys (HALS) (followed up >7 years) and the English Longitudinal Survey of Ageing (ELSA) (followed up >2 years). A model was developed using a 50% random sample from HALS and tested in the other 50% and in ELSA. We examined the association of risk of disease, functioning and engagement with society at baseline with confidence and continued engagement at follow-up. RESULTS: The model developed in the 50% sample of HALS was strong and reproducible in the other data sets. Low risk and good function at baseline are associated with confidence and continued engagement at follow-up, with engagement at baseline independently associated with engagement at follow-up. CONCLUSIONS: This model provides reproducible insights on the nature of ageing well, confirming the importance of personal resilience and continued involvement in physical and social activities. Far from retiring, engagement with life and society should be the norm for ageing populations.

The anatomy, physiology and pathogenesis of a significant untoward incident.

This paper provides a structured chronology of an investigation into a significant untoward incident in an elderly care ward. Using Reason's Swiss Cheese Model, which has become one of the dominant paradigms for analysing clinical and patient safety incidents, it charts the interplay of national and local policies resulting in unsafe practice. A qualitative approach was used in this multidimensional investigation. This approach aimed to discover what actually happened in the specific and related incidents and the underlying causes. Thus, the anatomy of the incident refers to the structure of staffing, the physiology includes the process in place at the time of the incident and the pathogenesis alludes to the development of the incident. The findings report on the patients involved in the incident. The investigation also explores how strategic financial directions from the Department of Health impact on staffing levels and training. These are contextualised using the concepts of the Swiss Cheese Model to assist understanding of how and why the incident occurred. Key points emanating from a learning event are captured to aid understanding and the importance of being cognisant of the ever present risks in clinical practice. The impact of the investigation on staff and the primary care trust are also presented.

Каковы возможные ответные меры систем здравоохранения в связи со старением населения?

Одной из наиболее важных демографических тенденций, с которыми сталкивается Европа, является старение ее населения. В данноманалитическом обзоре рассматриваются последствия, вытекающие из этого процесса для здравоохранения и длительного ухода, в том числе последствия с точки зрения средств, которые будут выделяться на медико-санитарную помощь, и требуемых расходов. В нем обсуждается ряд стратегических подходов, которые могут рассматриваться при принятии мер в ответ на проблему старения населения. Каких-либо конкретных рекомендаций в нем не дается, но отмечается, что на основании имеющихся данных исследований перспективным вариантом представляется содействие здоровому старению. В обзоре показано, что, когда у пожилых людей хорошее здоровье, на них нужно будет тратить меньше ресурсов здравоохранения и также выше вероятность того, что они сохранят трудовую активность. Стратегии, обеспечивающие здоровое старение населения, включают улучшение координации медицинских услуг и услуг длительного ухода и укрепление профилактических служб.

How can health systems respond to population ageing?

One of the most important demographic trends facing Europe is the ageing of its population. This policy brief considers the implications of this process for health and long-term care, including the funds available for health care and the expenditure required. It discusses a series of policy options that can be considered when responding to the challenge of an ageing population. Without making specific recommendations, it is noted that on the basis of the available research evidence, a promising option is to promote healthy ageing. When elderly people are in good health, it is shown that they will need fewer health care resources and are also more likely to remain in the labour force.Policies that allow a healthy ageing of the population include a better coordination of health and long-term care services and enhanced prevention services.

Policy brief 10: how can health systems respond to population ageing?

All countries in Europe are experiencing an ageing of their populations, a trend that is projected to continue until at least the middle of the twenty-first century. This process is often regarded as a major cause of upward pressure on health care costs. However, analyses of health care expenditure show that other factors, especially the increasing complexity of technology, carry greater impact. Furthermore, although population ageing will bring some additional costs, these can be reduced by the application of appropriate and well coordinated health and social policies that slow the rate of health decline associated with ageing and thus the amount of health care services required. Health trends among elderly people are complex. In some countries there is less severe disability than in the past, but generally an increase in mild disability and functional impairment can be observed. There is limited ability to treat effectively one of the most disabling common disorders, cognitive decline, and the accumulating burden of disease due to the obesity epidemic. The ability of older people to remain healthy and independent requires the provision of a supportive environment, including well-designed living conditions, access to economic resources, and appropriate health care. Health and social policies will thus need to deliver appropriate systems to respond to the needs of ageing populations. Given the important long-term implications, this remains