Gene discovery for oral ulceration: a UK Biobank Study

Background

Oral ulceration is a common, painful condition of uncertain aetiology. Ulcers are characterised by immune-mediated mucosal destruction, inflammation, and a proliferative healing phase. Oral ulceration is heritable but the genetic basis remains poorly characterised. We aimed to identify genetic risk factors for oral ulcers, and find evidence for a common genetic basis or causal association between oral ulceration and autoimmune traits.

Association of adverse childhood experiences with educational attainment and adolescent health,and the role of socioeconomic factors: analysis of a prospective cohort study

Background

There is increasing policy emphasis on adverse childhood experiences (ACEs). We aimed to assess the relative contributions of these experiences and socioeconomic factors to educational attainment and health.

Evaluating the impact of individual alcohol licensing decisions on local health and crime: a natural experiment with synthetic controls

BackgroundLocal authorities in England can influence the local alcohol environment by contributing to the licensing process and controlling the enforcement of existing licenses. However, a gap remains in the availability of quantitative evidence of effectiveness and impact of these local interventions, including a shortage of public health evidence around individual premises. Natural experiments offer the opportunity to evaluate these interventions where formal randomisation is not possible. We aimed to assess whether it is possible to quantitatively evaluate three natural experiments of alcohol licensing decisions at small spatial scale.MethodsThree situations presenting a natural experiment were identified in different English Local Authority areas by public health or licensing practitioners: (i) the closure of a nightclub in 2013, (ii) the closure of a restaurant-nightclub following reviews in 2016, and (iii) the implementation of new local licensing guidance (LLG) in 2013/14. We obtained monthly numbers of reported incidents of emergency department admissions for alcohol-related reasons, ambulance call-outs, and various crimes at lower/middle-super-output-area level (from 2010–14 for case i, 2015–17 for case ii, and 2008–14 for case iii). Bayesian structural timeseries were used to compare trends to their counterfactuals, approximated by synthetic controls based on time series of the same outcomes in other, comparable, areas.FindingsClosure of the nightclub was associated with temporary reductions in antisocial behaviour (–18%; 95% Bayesian Credible Interval [BCI] –37 to –4); equivalent to 60 averted incidents in 4 months. Closure of the restaurant-nightclub was not associated with measurable changes in outcomes. There was some evidence that the LLG introduction was associated with a reduction in drunk and disorderly behaviour (–42%, 95% BCI –109 to 23), but this reduction equated to less than one incident per month. The unplanned end of the LLG might have contributed to an increase in domestic violence (11%, 95% BCI –10 to 35), corresponding to two additional incidents per month.InterpretationIt is possible to evaluate the impact of local alcohol policies, even at the level of individual premises, using this methodology. We provide quantitative evidence that local government actions to influence the local alcohol environment can have a positive impact on health and crime in the area but could also have unintended consequences.FundingThis work was funded by the National Institute for Health Research School for Public Health Research (NIHR SPHR), a partnership between the Universities of Sheffield, Bristol, Cambridge, Exeter, and University College London); the London School for Hygiene and Tropical Medicine; the LiLaC collaboration between the Universities of Liverpool and Lancaster and Fuse; and the Centre for Translational Research in Public Health, a collaboration between Newcastle, Durham, Northumbria, Sunderland and Teesside Universities. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the UK Department of Health.     

Distribution of sexual health knowledge and attitudes in adolescent social networks: social network analysis of data from the STIs and Sexual Health feasibility study

Background

The social patterning of important precursors to sexual behaviour could help inform the potential reach of social network interventions. We aimed to investigate how peer networks might influence diffusion of sexual health messages in the context of a school-based peer-led sexual health intervention.

Cooperativity of streptococcal surface proteins in binding platelets and extracellular matrix

Background

The ability of the oral bacterium Streptococcus gordonii to bind platelets and extracellular matrix (ECM) contributes to its virulence in infective endocarditis. Surface protein PadA has recently been found to be crucial for platelet activation. The hypothesis is that PadA is dependent upon another surface protein (Hsa) for S gordonii to activate platelets and adhere to ECM. We aimed to determine the respective roles of Hsa and PadA in platelet adhesion, and ascertain PadA function in ECM binding.

Potential effects of universal basic income: a scoping review of evidence on impacts and study characteristics

Background

Unconditional basic income is seen as a potential solution to decreasing job security and predicted automation of many routine jobs. The importance of upstream health determinants suggests that basic income could improve health and reduce health inequalities. Since the effects of a universal, permanent basic income would differ from those of a trial, extrapolation of impacts from existing evidence is difficult. However, studies of interventions that unconditionally provide substantial, regular payments to individuals or families can provide insights into the potential effects. We conducted a scoping review to identify and synthesise evidence that could inform the planning stage of potential basic income pilots in Scotland.

Development of guidance for feasibility studies to decide whether and how to proceed to full-scale evaluation of complex public health interventions: a systematic review

Background

The importance of feasibility studies (also referred to as exploratory or pilot studies) for optimising complex public health interventions and evaluation designs before evaluating effectiveness is widely acknowledged. In a systematic review of guidance on feasibility studies, we found that guidance is lacking or inconsistent on many aspects of their purpose, design, and conduct, and that it is lacking on the evidence needed to inform decisions about when to proceed to an effectiveness study. This work, building on that review, aimed to develop guidance for researchers, peer reviewers, and funders.

Comparison of stakeholder coalitions across pricing policies designed to improve public health,as represented in UK newspapers: a discourse network analysis study

BackgroundNew methodological innovations are needed to better understand the role of complex stakeholder networks in gaining support for contested health policies. The news media provides a valuable setting for stakeholders to present arguments for and against such policies. We used two examples of UK policies, minimum unit pricing (MUP) for alcohol and the soft drinks industry levy (SDIL), to assess the value of discourse network analysis in comparing the competing discourse coalitions evident in the UK news media. We aimed to assess the similarities and differences in the composition and structure of policy discourse networks, and to find out whether public health advocates could use network insights to counter industry opposition to health policies.MethodsExisting discourse network analyses for MUP and SDIL were harmonised in Visone to allow direct comparison. We applied a common tie-weight threshold to reduce ties to robust argumentative similarities and used the Girvan-Newman edge-betweenness community detection algorithm to identify clusters of stakeholder subgroups with argumentative similarities within the discourse networks. We calculated network measures of size, density, and E-I index and used them to compare the principal coalitions in each network.FindingsBoth networks involved a similar range of stakeholder types and formed two discourse coalitions representing proponents and opponents of the policies. The SDIL network was larger (175 stakeholders) than the MUP network (87), particularly the proponents’ coalition (109 stakeholders for SDIL compared with 33 for MUP). The same concept (“policy is supported by the evidence”) was the most polarising concept in both networks. We were able to identify tight discourse coalitions of manufactures and commercial analysts acting in opposition to policy supporters in both debates. Public health actors appeared to be siloed in their areas of interest.InterpretationDiscourse network analysis enabled a novel direct comparison of the discourse coalitions across two highly contested pricing policy debates, allowing visualisation of the complex network of actors and relationships operating to potentially influence policy-making through the media. This method shows promise for better understanding of the common tactics used by different unhealthy commodity industries to disrupt public health policies and how public health actors could better work across policy and commodity arenas.FundingSH, CB, GF are funded by the UK Medical Research Council/Chief Scientist Office of the Scottish Government Health Directorates, and TH and PL by the University of Glasgow.     

Developing a model of citizenship for application within health and social care contexts: a community-based participatory approach

BackgroundCitizenship as a concept has often been understood in terms of the duties, rights, obligations, and functions a person has as a member of society. In health and social care policy and practice, the term has broader reach. This study explored what citizenship means to people with recent experience of mental illness, a long-term physical health condition, or involvement with the criminal justice, as well as to people who did not primarily identify as having experienced any of these major life disruptions. The aim was to develop an empirical model of citizenship to be applied within health and social care contexts.MethodsWe employed a mixed-methods, community-based, participatory research approach, with recruitment taking place between June, 2016, and February, 2019. Ten focus groups (n=77 participants) were conducted to generate statement items about the meaning of citizenship, and concept-mapping sessions with participants from the stakeholder groups (n=45) were held to categorise and rate each item in terms of importance and achievement. The number of statement items generated was further reduced after an online survey to ask participants (n=242) to rate items according to their clarity and relevance to the concept of citizenship. Multidimensional scaling and hierarchical cluster analysis were used to develop a five-cluster model of citizenship.Findings110 statement items about the meaning of citizenship were generated from a total of 703 items extracted from the focus groups, and were further reduced to 58 following the online survey. We identified five clusters representing the personal meanings of citizenship for participants: building relationships, autonomy and acceptance, access to services and supports, values and social roles, and civic rights and responsibilities. These clusters informed the development of the empirical model of citizenship to be applied within health and social care policy and practice.InterpretationThis multidimensional model of citizenship provides an empirical framework for policy makers and practitioners to set citizenship-based initiatives that contribute to the recovery and social inclusion of people who have experienced major life disruptions. This model will inform the development of a citizenship tool to facilitate discussions around citizenship.FundingTurning Point Scotland, The Scottish Recovery Network and Health and Social Care Alliance Scotland.     

Developing a new drug recovery community in the UK: a qualitative study of the transferability of an intervention from San Patrignano,Italy, to Scotland

Background

Although the Scottish Government's 2008 national drugs strategy (Road to Recovery) and HM Government's 2017 Drug Strategy emphasise recovery, drug-related deaths continue to increase. An alternative approach is being developed by Independence from Drugs and Alcohol Scotland (IFDAS) inspired by the successful drug recovery community in San Patrignano, Italy. In contrast to harm-reduction measures, a drug recovery community is a complex psychosocial intervention designed to address the wider social determinants of addiction. We aimed to assess the programme theory of the San Patrignano model to identify key mechanisms and stakeholders' perceptions of mechanisms considered essential to transfer to, and those that need adapting for, the new drug recovery community in Scotland.

Impact and implementation of active case finding for tuberculosis in homeless populations: a systematic review

BackgroundIdentifying tuberculosis in homeless populations through active case finding (ACF) is recommended to address health inequalities and contribute to wider control strategies for tuberculosis. We aimed to assess the effectiveness of ACF.MethodsThis systematic review assessed studies on ACF done in countries with low or medium burden of tuberculosis across Europe, the USA, and Australia. We systematically searched EMBASE, CINAHL Plus, ASSIA, Pro-Quest, Scopus, and the Cochrane Library and grey literature for English language publications up to Jan 5, 2019 (no earlier date limit). We used concepts of “ACF”, “tuberculosis”, and “homeless person”. We identified studies that analysed ACF and reported on our outcome measures, in homeless populations, in low-burden and medium-burden countries. ACF screening included testing for latent tuberculosis infection (LTBI) or active tuberculosis affecting any site. Studies into outbreak control or other populations were excluded. Primary study outcomes were the effectiveness of ACF (using population measures of tuberculosis prevalence or incidence) and interventions to improve ACF uptake and completion of the diagnostic pathway. Secondary outcomes were yield of ACF, cost-effectiveness, and characteristics of participants.Findings21 studies met the inclusion criteria. Study heterogeneity precluded meta-analysis. Three time-trend analyses produced some evidence that ACF was effective, because it was associated with reductions in tuberculosis incidence, prevalence, or clustering. A modelling study also showed that ACF was more effective than passive case finding in reducing population tuberculosis burden. Material incentives have the strongest evidence for improving uptake of ACF, with mixed evidence for peer educators. Observational evidence shows professional support and mandatory screening might also enhance uptake, and additional community-based support improves completion of the diagnostic pathway. Across all studies, the yield of screening (defined as the proportion of screened individuals who test positive) ranged from 1·5% to 57% for LTBI (total 41 684 individuals screened), and 0–3·1% for active tuberculosis (total 91 771 individuals screened). ACF can be cost-effective; population prevalence and screening modalities are determinants of cost-effectiveness. Considering ACF participants, subgroups most likely to be diagnosed with tuberculosis appeared less likely to accept screening.InterpretationACF should be considered in both tuberculosis and homelessness strategies, with evidence-based interventions to improve implementation. Outcomes varied widely, meaning programmes must be tailored to local populations. Strengths of our study include generalisable results to homeless populations from diverse settings. Limitations include restriction to the English language, the fairly low grade of the evidence identified, and the low number of studies screening for LTBI or using newer screening tests.FundingThe South West Public Health Training Programme.     

Health for wealth: decomposing the role of health on productivity in England using individual and population-level longitudinal data from the UK

BackgroundThe productivity gap between the north and rest of England is around £44 billion per year. There is a substantial health gap, with mean average life expectancy 2 years lower and increased morbidity in the north. This study estimated how much of the productivity difference between the north and rest of England can be explained by poor health.MethodsAn individual analysis used data from Understanding Society: The UK Household Longitudinal Study, an annual household survey of around 40 000 households from 2008–16. A macro-level analysis used longitudinal data from the Office for National Statistics and other sources at the local-authority level from 2004–17. Analysis was restricted to individuals of working age (18–64 years) without missing data. The outcome variable was productivity, measured at the individual level by employment rate and at local-authority level by gross value added per head. The key exposure variable was health, measured at the individual level by self-reported health, presence of a long-standing illness or impairment, and mental health measured by the general health questionnaire. At the population level, health was measured by mortality and the proportion of the working-age population claiming incapacity benefit as a proxy for morbidity. We used decomposition methods to estimate how productivity differences between the north and rest of England could be explained by health.FindingsAt the individual level, 33% of the regional differences in productivity between the north and rest of England could be explained by health. Poorer physical health contributed 24% to the regional differences and higher incidence of poor mental health contributed 9%. At the local-authority level, 30% of the productivity gap between the north and rest of England could be attributed to poorer health in the north, 17% by morbidity, and 12% by premature mortality. Based on these findings, if health were the same in both regions an additional £13·2 billion gross value added would be generated.InterpretationHealth improvement focusing on the north of England can increase UK productivity and promote regional growth. Our findings are robust to different proxies of productivity. However, we cannot establish a causal relationship between health and productivity.FundingNorthern Health Service Alliance.     

Mental wellbeing in prisoners in Scotland: an analysis of repeat cross-sectional surveys

Background

Mental ill-health is very common among people in prison. However, although mental wellbeing features high in health and justice policies, it has been little studied in this population. This study aimed to address this gap using a routine survey of people in prison in Scotland.

Design and validation of a questionnaire to assess household-level socioeconomic status: a mixed-methods study

Background

The systematic assessment of socioeconomic status (SES) of individual households in relation to health outcomes is considered the most important step to tackle inequalities in health systems. There is no valid and reliable questionnaire to evaluate household-level SES in low-to-middle-income countries. This study aimed to design and validate a questionnaire to assess household-level SES.

Mining electronic health records to identify influential predictors associated with hospital admission of patients with dementia: an artificial intelligence approach

Background

Early prediction of the outcomes of dementia is important and challenging. This study aimed to identify influential predictors from primary care electronic health records that can robustly predict whether patients with dementia will be admitted to hospital or remain under GP care.

Validity of using UK primary care electronic health records to study migration and health: a population-based cohort study

BackgroundDespite international migrants comprising 15·6% of the English population, there are no large-scale studies of migrant health in UK primary care electronic health records (EHRs). Developing and validating a migration phenotype (a transparent reproducible algorithm based on EHRs to identify migrants) is necessary to determine the feasibility of using EHRs for migration health research. This study aims to develop and validate a migrant phenotype in Clinical Practice Research Datalink (CPRD), the largest UK primary care EHR.MethodsThis is a population-based cohort study of individuals of any age in CPRD between Jan 1, 2007, and Feb 29, 2016, with a diagnostic Read term indicating international migration. We describe completeness of recording of migration: percentage of individuals recorded as migrants over time. We also describe representativeness of the cohort (age, sex, and geographical origin) compared with data from the Office of National Statistics (ONS; country of birth and the 2011 English Census).Findings325 391 (3·4%) of 9,448,898 individuals in CPRD had at least one of 440 terms indicating international migration. The cohort was mostly female (53·7% [174 883/325 391] overall; 52·4% [55 734/106 462] in 2011), which is similar to ONS 2011 census data (51·7 [3 791 375/7 337 139]). The percentage of migrants per year increased from 1·2% (69 046/5 716 075) in 2007 to 2·8 (154 525/5 427 745) in 2013, following a similar trend to ONS migration data (11·7% [5 927 000/50 714 000] in 2007; 13·7% [7 285 000/53 164 000] in 2013). Proportions were significantly lower in CPRD (χ² test; p<0·0001). The highest percentages of migrants were in the 25–34-year-old band (4·6% [30 549/668 864] in CPRD; 25·9% [1 851 952/7 160 102] in ONS). Migrants were mostly born in Europe (35·4% [10 316/29 113] in CPRD; 36·5% [2 675 003/7 337 042] in ONS) or the Middle East and Asia (34·5% [10 037/29 113] in CPRD; 34·5% [2 529 137/7 337 042] in ONS).InterpretationWe created a cohort of international migrants in England that is broadly representative in terms of age, sex, and geographical region of origin. Future validation work should explore representativeness by ethnicity and deprivation. Potential reasons for undersampling compared with ONS data include insufficient recording and poor health-care access. Nonetheless, the large cohort size provides sufficient power to study a range of health-care analyses in this potentially underserved population.FundingWellcome Trust (approvals [CPRD ISAC 19_062R]; REC 09/H0810/16).     

Mapping alcohol and tobacco tax interventions for health in the UK: a qualitative framework analysis

BackgroundAlcohol and tobacco use undermine population health, generating substantial costs. Increasing price is an effective means to reduce consumption and tax is a key harm reduction tool. In the UK, alcohol and tobacco tax are managed within fiscal policy, which does not necessarily prioritise health promotion. We aimed to map the objectives and options for alcohol and tobacco tax change in the UK, including the potential for greater coordination to improve health.MethodsWe did five semi-structured interviews with ten participants selected for their expertise in alcohol or tobacco tax policy. Interviews occurred in pairs (ie, one alcohol and one tobacco expert in each interview) to elicit comparison between substances and were supported by a rapid literature review of tax options. Participants were from government, arms-length governmental organisations, and advocacy groups. Informed by a rapid literature review, comparative framework analysis of alcohol and tobacco tax policy objectives, options, and factors pertaining to coordination between tobacco and alcohol was done.FindingsParticipants raised common health objectives (reducing consumption, harm, inequalities) and fiscal objectives (raising revenue, mitigating societal costs). Drawing on options identified in the rapid review, participants discussed common tax options to achieve these objectives: tax rate increases (sudden rises, annual increases, minimum thresholds), changing tax structures (taxing products differently, tax proportional to harm), levies (taxing retailers and manufacturers), and revenue hypothecation (for prevention or treatment of addiction, local services). Participants were positive about policy exchange across alcohol and tobacco and modelling the combined effect of tax changes, but uncertain about formally linking tax policy across substances.InterpretationRaising tax is often considered to improve health by making products less affordable, but a tax regime that raises additional revenue can support prevention and treatment services and mitigate the social and economic costs of consumption. An unresolved issue for policy debate is who should pay this revenue and how revenue would be maintained if the health objective of falling consumption were met. Although more input from fiscal policymakers would deepen findings, our rapid review and interview approach facilitated discussion across alcohol and tobacco, and use of the framework approach ensured consistent analysis.FundingNational Institute of Health Research Public Health Research programme.     

Socio-demographic and economic determinants of overweight and obesity in preschool children in Palestine: analysis of data from the Palestinian Multiple Indicator Cluster Survey

Background

Obesity is a global public health issue and worldwide rates of childhood obesity are ten times higher than 40 years ago. A limited number of studies have been conducted to determine the prevalence of preschool obesity and overweight and associated factors in Palestinian children. The aim of this study was to examine sociodemographic and economic factors associated with preschool overweight and obesity in Palestinian children younger than 5 years of age.