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In England, the Environment Agency (EA) estimates that over 3 million properties in England are at risk of surface water flooding. Heavy and prolonged rainfall that drives surface water flooding is projected to increase in the future due to climate change. This paper presents a quantitative secondary analysis of a cross-sectional household flood survey in a disadvantaged city in England heavily impacted by surface water flooding in 2007 and at severe risk of flooding in the future. The aim of this study was to examine how previous experience of flooding, demographic factors, and behaviours impact on feelings of protection against flooding and perceived ability to recover from flooding. Survey data were collected from residents in Hull in northern England in 2018, in areas impacted by major floods in 2007 when over 8,600 households were flooded. Valid responses were received from 453 households, of whom 37.3% were flooded or flooding damaged their house (n = 169), 14.6% had been disrupted by flooding (n = 66), 9.3% had been exposed to flooding (n = 42) and 176 (38.9%) had not experienced flooding. Over 22% felt they had very low protection against flooding, and over 25% would make a very slow recovery if they were flooded. Associations were found between gender and both low levels of protection against flooding. Females were less likely to feel confident in their recovery from flooding than males (OR 0.551). The findings support a need to focus on women's perceptions of flood vulnerability and capacity to cope and recover from flooding in flood and disaster management policy and practice, including providing effective support before, during and after flooding., Competing Interests: No competing interests., (Copyright: © 2024 Twiddy, Ramsden. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Over the last decade, the strain on the English National Health Service (NHS) has increased. This has been especially felt by acute hospital trusts where the volume of admissions has steadily increased. Patient outcomes, including inpatient mortality, vary between trusts. The extent to which these differences are explained by systems-based factors, and whether they are avoidable, is unclear. Few studies have investigated these relationships. A systems-based methodology recognises the complexity of influences on healthcare outcomes. Rather than clinical interventions alone, the resources supporting a patient's treatment journey have near-equal importance. This paper first identifies suitable metrics of resource and demand within healthcare delivery from routinely collected, publicly available, hospital-level data. Then it proceeds to use univariate and multivariable linear regression to associate such systems-based factors with standardised mortality. Three sequential cross-sectional analyses were performed, spanning the last decade. The results of the univariate regression analyses show clear relationships between five out of the six selected predictor variables and standardised mortality. When these five predicators are included within a multivariable regression analysis, they reliably explain approximately 36% of the variation in standardised mortality between hospital trusts. Three factors are consistently statistically significant: the number of doctors per hospital bed, bed occupancy, and the percentage of patients who are placed in a bed within four hours after a decision to admit them. Of these, the number of doctors per bed had the strongest effect. Linear regression assumption testing and a robustness analysis indicate the observations have internal validity. However, our empirical strategy cannot determine causality and our findings should not be interpreted as established causal relationships. This study provides hypothesis-generating evidence of significant relationships between systems-based factors of healthcare delivery and standardised mortality. These have relevance to clinicians and policymakers alike. While identifying causal relationships between the predictors is left to the future, it establishes an important paradigm for further research., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Gardner, Kristensen. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Since the early 2000s, there have been marked trends in adolescent health and wellbeing indicators across Europe, North America and Australia. In particular, there have been substantial declines in youth drinking. We know little about how these trends are underpinned by co-occurring indicators within individuals. This paper aims to analyse change over time in how indicators cluster within individuals and differences in these patterns between five countries with different trends in youth drinking., Methods: We analysed four waves of repeat cross-sectional survey data from 15-year-olds in England (n = 5942), Italy (n = 5234), the Netherlands (n = 5408), Hungary (n = 5274), and Finland (n = 7446), which were included in the Health Behaviours in School-aged Children (HBSC) study between 2001/02 and 2013/14. We defined clusters of individuals using multigroup latent class analyses which accounts for change over time. The class indicators included health behaviours, attitudes, wellbeing and relationships. We modelled associations between class membership, sex, and family affluence over time., Results: We identified four classes in all countries: Overall unhealthy, Overall healthy, Moderately healthy and Substance abstainers with behaviour risk indicators. The proportion of adolescents in the Overall unhealthy class declined between 2001/02 and 2013/14 by between 22.8 percentage points (pp) in England and 3.2pp in Italy. The extent to which indicators of health and wellbeing changed as linked clusters differed across countries, but changes in alcohol consumption, smoking, drug use and sexual activity were typically concurrent. Adolescents with low family affluence were more likely to be in the Overall unhealthy class in all years., Conclusions: Improvements in indicators of adolescent health and well-being are due mainly to concurrent declines in drinking, smoking, sexual activity, and cannabis use, but these declines are not consistently associated with improvements in other domains. They have also not led to reductions in inequalities in indicators of health and well-being., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Stevely et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Childhood, adolescent and young adult (CAYA) cancer survivors are vulnerable to adverse late-effects. For CAYA cancer survivors, tobacco smoking is the most important preventable cause of ill-health and early death. Yet, effective strategies to support smoking cessation in this group are lacking. The PRISM study aims to undertake multi-method formative research to explore the need for, and if appropriate, inform the future development of an evidence-based and theory-informed tobacco smoking cessation intervention for CAYA cancer survivors., Materials and Methods: PRISM involves three phases of: 1) an environmental scan using multiple strategies to identify and examine a) smoking cessation interventions for CAYA cancer survivors that are published in the international literature and b) current smoking cessation services in England that may be available to, or tailorable to, CAYA cancer survivors; 2) a qualitative study involving semi-structured interviews with CAYA cancer survivors (aged 16-29 years and who are current or recent ex-smokers and/or current vapers) to explore their views and experiences of smoking, smoking cessation and vaping; and 3) stakeholder workshops with survivors, healthcare professionals and other stakeholders to consider the potential for a smoking cessation intervention for CAYA cancer survivors and what such an intervention would need to target and change. Findings will be disseminated to patient groups, healthcare professionals and researchers, through conference presentations, journal papers, plain English summaries and social media., Discussion: PRISM will explore current delivery of, perceived need for, and barriers and facilitators to, smoking cessation advice and support to CAYA cancer survivors from the perspective of both survivors and healthcare professionals. A key strength of PRISM is the user involvement throughout the study and the additional exploration of survivors' views on vaping, a behaviour which often co-occurs with smoking. PRISM is the first step in the development of a person-centred, evidence- and theory-based smoking cessation intervention for CAYA cancer survivors who smoke, which if effective, will reduce morbidity and mortality in the CAYA cancer survivor population., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Brown et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: The aim of this paper is to investigate what factors are associated to cardiovascular disease and what differences exists between Asians living in the UK (from the English Longitudinal Study of Ageing) and the Asians living in India (from the Longitudinal Ageing Study in India)., Methods: Logistic regression was used to investigate how demographic and physical performance factors were associated with cardiovascular disease using data from Wave 6 of the English Longitudinal Study of Ageing and Wave 1 of the Longitudinal Study of Ageing in India, with the main variable of interest being country of residence, Asians in England or Asians in India., Results: A total of 83,997 participants were included in the analyses. In the primary analysis, 73,396 participants from LASI were compared to 171 Asians in ELSA. After adjusting for age, blood pressure, resting heart rate, sex, waist circumference, gait, handgrip strength and standing balance, there was a statistically significant difference for the outcome of CVD between Whites ELSA (reference) and the participants of LASI (odds ratio = 0.77; 95% confidence interval = 0.60 to 0.99). There were no significant differences in CVD between the LASI participants, Asian ELSA, and the Non-White but not Asian ELSA groups., Discussion: No difference was found between Asians that live in India compared to ethnic minorities living in England, including Asians, after adjusting for confounders, but was found between Whites in ELSA compared to LASI participants. A key limitation was the massive disparity in sample sizes between the ELSA subgroups and LASI. Further work is required where comparable sample sizes and longitudinal analyses allow trends to be identified and to investigate the factors associated with the difference in CVD between two similar ethnicities living in distinct locations., Conclusion: After adjusting for risk factors, there was no difference in CVD between localised Asians and the ethnic minorities in the UK, but there was a difference between the majority ethnicities in the respective countries., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Patel, Uthman. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Although both the analysis of regional culture and urbanisation are long-standing preoccupations in geography, few studies have considered the relationship between the two, the former traditionally being a topic in cultural geography, while the latter is usually interpreted and analysed as a process in economic geography. Taking evidence from the 1851-1911 censuses of England and Wales, this article analyses individual migration paths to identify stable regions of human interaction by applying a sophisticated community-detection algorithm. By accurately mapping the regions within which the majority of migration occurred between 1851 and 1911 and arguing that the stability of these geographies is evidence of more than just mutable communities but rather of persistent regional cultures, this article responds to previous studies that have sought to identify the cultural provinces of England and Wales. Indeed, by demonstrating that the regions bear a striking resemblance to those that have long been hypothesised as being distinct cultural provinces of England and Wales, this article empirically corroborates their existence. In order to further demonstrate that the regions constitute cultural provinces, this paper incorporates these boundaries into a spatial interaction model (SIM). The results of the SIM not only shows that the boundaries between the regions limited the number of migrants that crossed them-over and above that explained by control variables-and therefore represented the boundaries of cultural provinces, demarcating discrete regions of human interaction-but that such boundaries disproportionately restricted rural-urban migrants, thereby slowing the pace at which England and Wales urbanised. This paper therefore demonstrates that urbanisation should not only be interpreted as only an economic phenomenon, but a cultural one also, and that if urbanisation is to be fully understood, individuals' attachment to place as a component of their identity, ought to be formally incorporated into models of migration., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Joseph Day. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Delivering care to growing numbers of patients with increasingly 'complex' needs is currently compromised by a system designed to treat patients within organizational clinical specialties, making this difficult to reconfigure to fit care to needs. Problematic experiences of people with cognitive impairment(s) admitted to hospitals with a hip fracture, exemplify the complex challenges that result if their care is not tailored. This study explored whether a flexible, multicomponent intervention, adapting services to the needs of this patient group, could be implemented in acute hospital settings., Methods: We used action research with case study design to introduce the intervention using a Plan-Do-Study-Act (PDSA) model to three different hospital sites (cases) across England. The qualitative data for this paper was researcher-generated (notes from observations and teleconference meetings) and change agent-generated (action plans and weekly reflective reports of change agents' activities). Normalization Process Theory (NPT) was used to analyze and explain the work of interacting actors in implementing and then normalizing (embedding) the intervention across contexts and times. Data analysis was abductive, generating inductive codes then identified with NPT constructs. Across the three cases, change agents had to work through numerous implementation challenges: needing to make sense of the intervention package, the PDSA model as implementation method, and their own role as change agents and to orientate these within their action context (coherence). They had to work to encourage colleagues to invest in these changes (cognitive participation) and find ways to implement the intervention by mobilising changes (collective action). Finally, they created strategies for clinical routines to continue to self-review, reconfiguring actions and future plans to enable the intervention to be sustained (reflexive monitoring)., Conclusions: Successful implementation of the (PERFECT-ER) intervention requires change agents to recognize and engage with local values, and then to enable its fit with practice and wider contextual goals. A context of constant change fragments normalization. Thus, sustaining practice change over time is fragile and requires change agents to continue a recursive two-way sense-making process. This enables implementation and normalization to re-energize and overcome barriers to change., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Fox et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

With increasing costs of healthcare in England and Wales following the COVID-19 pandemic, finding alternatives to traditional medical interventions is more important than ever. Social prescribing provides a way of addressing health and well-being through using non-medical methods that may help relieve costs to the NHS. Evaluating interventions, such as social prescribing, which have high social (but not easily quantifiable) value, can be problematic. Social return on investment (SROI) is a method of assigning monetary values to both social value as well as traditional assets, so provides a way of evaluating social prescribing initiatives. This protocol outlines the steps that will be taken in a systematic review of the SROI literature surrounding social prescribing-type integrated health and social care interventions based in the community in England and Wales. Online academic databases such as PubMed Central, ASSIA and Web of Science will be searched, as will grey literature sources such as Google Scholar, the Wales School for Social Prescribing Research (WSSPR) and Social Value UK. Titles and abstracts from the articles returned by the searches will be reviewed by one researcher. Those selected for full text review will be independently reviewed and compared by two researchers. Where the researchers disagree a third reviewer will help resolve any differences. Information collected will include identifying stakeholder groups, assessing the quality of SROI analyses, identifying intended and unintended changes of social prescribing interventions, and comparing social prescribing initiatives in terms of SROI costs and benefits. Quality assessment will be independently conducted on the selected papers by two researchers. The researchers will discuss to obtain consensus. Where there is disagreement, a third researcher will resolve these cases. A pre-existing quality framework will be developed and used to assess the quality of the literature. Protocol registration Prospero registration number: CRD42022318911., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Hopkins et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Aims and Objectives: This paper aims to improve understanding of factors that contribute to persistent ethnic disparities in patient satisfaction in England. The specific objectives are to (i) examine ethnic differences in patient satisfaction with their primary care in England; and (ii) establish factors that contribute to ethnic differences in patient satisfaction., Data and Methods: The study is based on secondary analysis of recent General Practitioner Patient Survey (GPPS) datasets of 2019, 2020 and 2021. Descriptive bivariate analysis was used to examine ethnic differences in patient satisfaction across the three years. This was followed with multilevel linear regression, with General Practice (GP) at level-1 and Clinical Commissioning Group (CCG) at level-2 to identify factors contributing to ethnic differences in patient satisfaction., Results: The findings show consistent negative correlations between the proportion of patients reporting good (very or fairly good) overall experience and each of the ethnic minority groups. Further examination of the distribution of patient satisfaction by ethnicity, based on combined ethnic minority groups, depicted a clear negative association between ethnic minority group and patient satisfaction at both GP and CCG levels. Multilevel regression analysis identified several service-related factors (especially ease of using GP website and being treated with care and concern) that largely explained the ethnic differences in patient satisfaction. Of all factors relating to patient characteristics considered in the analysis, none was significant after controlling for GP service-related factors., Conclusions: Ethnic minority patients in England continue to consistently report lower satisfaction with their primary health care in recent years. This is largely attributable to supply (service related) rather than demand (patient characteristics) factors. These findings have important implications for health care system policy and practice at both GP and CCG levels in England., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Magadi, Magadi. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Understanding the scale of the threat posed by SARS-CoV2 B.1.1.529, or Omicron, variant formed a key problem in public health in the early part of 2022. Early evidence indicated that the variant was more transmissible and less severe than previous variants. As the virus was expected to spread quickly through the population of England, it was important that some understanding of the immunological landscape of the country was developed. This paper attempts to estimate the number of people with good immunity to the Omicron variant, defined as either recent infection with two doses of vaccine, or two doses of vaccine with a recent booster dose. To achieve this, we use a process of iterative proportional fitting to estimate the cell values of a contingency table, using national immunisation records and real-time model infection estimates as marginal values. Our results indicate that, despite the increased risk of immune evasion with the Omicron variant, a high proportion of England's population had good immunity to the virus, particularly in older age groups. However, low rates of immunity in younger populations may allow endemic infection to persist for some time., Competing Interests: The authors have declared that no competing interests exist.

Background: There is uncertainty around the health impact and economic costs of the recent slowing of the historical decline in cardiovascular disease (CVD) incidence and the future impact on dementia and disability., Methods: Previously validated IMPACT Better Ageing Markov model for England and Wales, integrating English Longitudinal Study of Ageing (ELSA) data for 17,906 ELSA participants followed from 1998 to 2012, linked to NHS Hospital Episode Statistics. Counterfactual design comparing two scenarios: Scenario 1. CVD Plateau-age-specific CVD incidence remains at 2011 levels, thus continuing recent trends. Scenario 2. CVD Fall-age-specific CVD incidence goes on declining, following longer-term trends. The main outcome measures were age-related healthcare costs, social care costs, opportunity costs of informal care, and quality adjusted life years (valued at £60,000 per QALY)., Findings: The total 10 year cumulative incremental net monetary cost associated with a persistent plateauing of CVD would be approximately £54 billion (95% uncertainty interval £14.3-£96.2 billion), made up of some £13 billion (£8.8-£16.7 billion) healthcare costs, £1.5 billion (-£0.9-£4.0 billion) social care costs, £8 billion (£3.4-£12.8 billion) informal care and £32 billion (£0.3-£67.6 billion) value of lost QALYs., Interpretation: After previous, dramatic falls, CVD incidence has recently plateaued. That slowdown could substantially increase health and social care costs over the next ten years. Healthcare costs are likely to increase more than social care costs in absolute terms, but social care costs will increase more in relative terms. Given the links between COVID-19 and cardiovascular health, effective cardiovascular prevention policies need to be revitalised urgently., Competing Interests: All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. Dr Collins is currently on secondment as Head of Health Economics in Welsh Government; this paper does not represent any views of Welsh Government. Dr Pearson-Stuttard is also Head of Health Analytics at a commercial company, Lane Clark & Peacock LLP, vice-chair of the Royal Society for Public Health and reports personal fees from Novo Nordisk A/S, all outside of the submitted work. This work was completed as part of Dr Pearson-Stuttard’s academic appointment at Imperial College London.

Introduction: The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood., Aim: To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN., Methods: Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies., Results: Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate., Discussion: Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support., Competing Interests: The authors have declared that no competing interests exist.

Although there has been extensive research on pharmaceutical industry payments to healthcare professionals, healthcare organisations with key roles in health systems have received little attention. We seek to contribute to addressing this gap in research by examining drug company payments to General Practices in England in 2015. We combine a publicly available payments database managed by the pharmaceutical industry with datasets covering key practice characteristics. We find that practices were an important target of company payments, receiving £2,726,018, equivalent to 6.5% of the value of payments to all healthcare organisations in England. Payments to practices were highly concentrated and specific companies were also highly dominant. The top 10 donors and the top 10 recipients amassed 87.9% and 13.6% of the value of payments, respectively. Practices with more patients, a greater proportion of elderly patients, and those in more affluent areas received significantly more payments on average. However, the patterns of payments were similar across England's regions. We also found that company networks-established by making payments to the same practices-were largely dominated by a single company, which was also by far the biggest donor. Greater policy attention is required to the risk of financial dependency and conflicts of interests that might arise from payments to practices and to organisational conflicts of interests more broadly. Our research also demonstrates that the comprehensiveness and quality of payment data disclosed via industry self-regulatory arrangements needs improvement. More interconnectivity between payment data and other datasets is needed to capture company marketing strategies systematically., Competing Interests: PO’s PhD student was supported by a grant from Sigma Pharmaceuticals, a UK pharmacy wholesaler and distributor (not a pharmaceutical company). The PhD work funded by Sigma Pharmaceuticals is unrelated to the subject of this paper. SM’s partner is employed by PRA Health Sciences, a global Contract Research Organization whose costumers include many pharmaceutical companies. ES has no conflicts of interest to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: In 2017 Public Health England and Sport England commissioned a Consultant-led Sport and Exercise Medicine (SEM) pilot to test the feasibility and acceptability of embedding physical activity interventions in secondary care clinical pathways. The aim of this paper is to report qualitative findings exploring the experience of healthcare professionals (HCPs) and patients involved in the Active Hospital pilot., Methods: Qualitative data was collected by semi-structured interviews with Active Hospital pilot SEM Consultants, and staff and patients involved in three clinical pathways. Interviews with SEM Consultants explored the experience of developing and implementing the pilot. Interviews with staff and patients explored the experience of delivering and receiving Active Hospital interventions. Data were analysed thematically., Results: Interviews identified the importance of the Active Hospital pilot being Consultant-led for the following reasons; i) having trusting relationships with decision makers, ii) having sufficient influence to effect change, iii) identifying champions within the system, and iv) being adaptable to change and ensuring the programme fits within the wider strategic frameworks. HCPs emphasised the importance of the Active Hospital interventions fitting easily within existing work practices, the need for staff training and to tailor interventions for individual patient needs. The Active Hospital pilot was well received by patients, however a lack of dedicated resource and capacity to deliver the intervention was highlighted as a challenge by both patients and HCPs., Conclusion: The SEM Consultants' ability to navigate the political climate of a large National Health Service (NHS) Trust with competing agendas and limited resource was valuable. The interventions were well received and a valued addition to usual clinical care. However, implementation and ongoing delivery of the pilot encountered challenges including lack of capacity within the system and delays with recruiting to the delivery teams in each pathway., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To investigate whether partner bereavement is associated with adverse cardiovascular and kidney-related events in people with reduced kidney function., Design: Two parallel matched cohort studies using linked routinely collected health data., Setting: England (general practices and hospitals using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office of National Statistics) and Denmark (hospitals and community pharmacies using the Danish National Patient, Prescription and Education Registries and the Civil Registration System)., Participants: Bereaved people with reduced kidney function (estimated glomerular filtration rate (eGFR) <60mL/min/1.73m2 (England) or hospital-coded chronic kidney disease (Denmark)) and non-bereaved people with reduced kidney function similarly defined, matched on age, sex, general practice (England), and county of residence (Denmark) and followed-up from the bereavement date of the exposed person., Main Outcome Measures: Cardiovascular disease (CVD) or acute kidney injury (AKI) hospitalization, or death., Results: In people with reduced kidney function, we identified 19,820 (England) and 5,408 (Denmark) bereaved individuals and matched them with 134,828 (England) and 35,741 (Denmark) non-bereaved individuals. Among the bereaved, the rates of hospitalizations (per 1000 person-years) with CVD were 31.7 (95%-CI: 30.5-32.9) in England and 78.8 (95%-CI: 74.9-82.9) in Denmark; the rates of hospitalizations with AKI were 13.2 (95%-CI: 12.5-14.0) in England and 11.2 (95%-CI: 9.9-12.7) in Denmark; and the rates of death were 70.2 (95%-CI: 68.5-72.0) in England and 126.4 (95%-CI: 121.8-131.1) in Denmark. After adjusting for confounders, we found increased rates of CVD (England, HR 1.06 [95%-CI: 1.01-1.12]; Denmark, HR 1.10 [95%-CI: 1.04-1.17]), of AKI (England, HR 1.20 [95%-CI: 1.10-1.31]; Denmark HR 1.36 [95%-CI: 1.17-1.58]), and of death (England, HR 1.10 [95%-CI: 1.05-1.14]; Denmark HR 1.20 [95%-CI: 1.15-1.25]) in bereaved compared with non-bereaved people., Conclusions: Partner bereavement is associated with an increased rate of CVD and AKI hospitalization, and death in people with reduced kidney function. Additional supportive care for this at-risk population may help prevent serious adverse events., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: All authors have completed an ICJME disclosure form. AH, PB, AK, AYSW, SAJS declare no competing interests, including relevant financial interests, activities, relationships or affiliations. SVV was supported by The Beckett Foundation by a grant administered by Aarhus University which supported this manuscript. DN is the UK Renal Association Director of Informatics Research, a member of the steering group for two GlaxoSmithKline funded studies of kidney function in Sub-Saharan Africa and receives funding from the Health Foundation and the Medical Research Council unrelated to the work in this paper. SVV, CFC, and AK are members of Aarhus University Department of Clinical Epidemiology and are involved in studies with funding from various companies as research grants to (and administered by) Aarhus University. SML is funded by a Wellcome Senior Clinical Fellowship in Science (205039/Z/16/Z) and was funded by the European Academy of Dermatology and Venerology (PPRC-2016-019) for previous bereavement-related research. SL has received consulting fees from STAART-AKI Study Group (reviewing patient information sheets) and the NIHR (lay reviewer), has received payments for medical writing or editing from Kidney Care UK, ERA-EDTA for work unrelated to this manuscript. SL has also received support for travel at ERA-EDTA Congress 2018 and 2019 unrelated to this work. SL is also chair of the UK Renal Association Patients’ Council and the Guy’s & St Thomas’ Kidney Patients’ Association.

Detail is a double edged sword in epidemiological modelling. The inclusion of mechanistic detail in models of highly complex systems has the potential to increase realism, but it also increases the number of modelling assumptions, which become harder to check as their possible interactions multiply. In a major study of the Covid-19 epidemic in England, Knock et al. (2020) fit an age structured SEIR model with added health service compartments to data on deaths, hospitalization and test results from Covid-19 in seven English regions for the period March to December 2020. The simplest version of the model has 684 states per region. One main conclusion is that only full lockdowns brought the pathogen reproduction number, R, below one, with R ≫ 1 in all regions on the eve of March 2020 lockdown. We critically evaluate the Knock et al. epidemiological model, and the semi-causal conclusions made using it, based on an independent reimplementation of the model designed to allow relaxation of some of its strong assumptions. In particular, Knock et al. model the effect on transmission of both non-pharmaceutical interventions and other effects, such as weather, using a piecewise linear function, b(t), with 12 breakpoints at selected government announcement or intervention dates. We replace this representation by a smoothing spline with time varying smoothness, thereby allowing the form of b(t) to be substantially more data driven, and we check that the corresponding smoothness assumption is not driving our results. We also reset the mean incubation time and time from first symptoms to hospitalisation, used in the model, to values implied by the papers cited by Knock et al. as the source of these quantities. We conclude that there is no sound basis for using the Knock et al. model and their analysis to make counterfactual statements about the number of deaths that would have occurred with different lockdown timings. However, if fits of this epidemiological model structure are viewed as a reasonable basis for inference about the time course of incidence and R, then without very strong modelling assumptions, the pathogen reproduction number was probably below one, and incidence in substantial decline, some days before either of the first two English national lockdowns. This result coincides with that obtained by more direct attempts to reconstruct incidence. Of course it does not imply that lockdowns had no effect, but it does suggest that other non-pharmaceutical interventions (NPIs) may have been much more effective than Knock et al. imply, and that full lockdowns were probably not the cause of R dropping below one., Competing Interests: The authors have declared that no competing interests exist.

The prevalence of dyslexia identification has increased significantly over the last two decades. Yet there is debate over whether there are distinct biological and cognitive differences between those with literacy difficulties and the subgroup of people identified as dyslexic. This is the first paper that provides evidence for this ongoing debate by investigating the socio-demographic factors, outside biology and cognition, that predict whether a child is identified as dyslexic in the UK. Using secondary data from the UK's Millennium Cohort Study, this paper examines the socio-demographic factors that predict whether a child's teacher identifies them as dyslexic at age 11. Gender, season of birth, socio-economic class and parental income are found to be significant predictors of the dyslexia label. Therefore, factors seemingly unrelated to the clinical aspects of dyslexia influence whether a child is identified as dyslexic in England and Wales. This suggests that label may not be evenly distributed across a population; furthermore, it may also indicate that resources for support may not be fairly allocated. The findings further support the argument that a 'dyslexic sub-group' within poor readers is created due to the impact of environmental factors. The results from this national-scale study thus questions the reliability, validity and moral integrity of the allocation of the dyslexia label across current education systems in the UK., Competing Interests: The authors have declared that no competing interests exist.

Background: The Global Digital Exemplar (GDE) Programme was designed to promote the digitisation of hospital services in England. Selected provider organisations that were reasonably digitally-mature were funded with the expectation that they would achieve internationally recognised levels of excellence and act as exemplars ('GDE sites') and share their learning with somewhat less digitally-mature Fast Follower (FF) sites., Aims: This paper explores how partnerships between GDE and FF sites have promoted knowledge sharing and learning between organisations., Methods: We conducted an independent qualitative longitudinal evaluation of the GDE Programme, collecting data across 36 provider organisations (including acute, mental health and speciality), 12 of which we studied as in-depth ethnographic case studies. We used a combination of semi-structured interviews with programme leads, vendors and national policy leads, non-participant observations of meetings and workshops, and analysed national and local documents. This allowed us to explore both how inter-organisational learning and knowledge sharing was planned, and how it played out in practice. Thematic qualitative analysis, combining findings from diverse data sources, was facilitated by NVivo 11 and drew on sociotechnical systems theory., Results: Formally established GDE and FF partnerships were perceived to enhance learning and accelerate adoption of technologies in most pairings. They were seen to be most successful where they had encouraged, and were supported by, informal knowledge networking, driven by the mutual benefits of information sharing. Informal networking was enhanced where the benefits were maximised (for example where paired sites had implemented the same technological system) and networking costs minimised (for example by geographical proximity, prior links and institutional alignment). Although the intervention anticipated uni-directional learning between exemplar sites and 'followers', in most cases we observed a two-way flow of information, with GDEs also learning from FFs, through informal networking which also extended to other health service providers outside the Programme. The efforts of the GDE Programme to establish a learning ecosystem has enhanced the profile of shared learning within the NHS., Conclusions: Inter-organisational partnerships have produced significant gains for both follower (FF) and exemplar (GDE) sites. Formal linkages were most effective where they had facilitated, and were supported by, informal networking. Informal networking was driven by the mutual benefits of information sharing and was optimised where sites were well aligned in terms of technology, geography and culture. Misalignments that created barriers to networking between organisations in a few cases were attributed to inappropriate choice of partners. Policy makers seeking to promote learning through centrally directed mechanisms need to create a framework that enables networking and informal knowledge transfer, allowing local organisations to develop bottom-up collaboration and exchanges, where they are productive, in an organic manner., Competing Interests: All authors are investigators on the evaluation of the Global Digital Exemplars Programme (http://www.ed.ac.uk/usher) AS was a member of the Working Group that produced “Making IT Work” and was an assessor in selecting GDE sites. BDF supervises a PhD partly financed by Cerner, unrelated to this paper. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Cognitive behavioural therapy (CBT) which includes Exposure and Response (ERP) is a highly effective, gold standard treatment for Obsessive-Compulsive Disorder (OCD). Nonetheless, not all patients with OCD significantly benefit from CBT. This has generated interest in the potential benefits of Mindfulness-Based Interventions (MBIs), either integrated with CBT, to enhance engagement with ERP tasks, or delivered as a stand-alone, first-line or therapy to augment CBT. This paper reports on two qualitative studies that involved a thematic analysis of interview data with participants in a 10-week Mindfulness-Based ERP (MB-ERP) course (study 1) and a 9-week Mindfulness-Based Cognitive Therapy course adapted for OCD (MBCT-OCD) (study 2). Whilst MB-ERP integrated a mindfulness component into a standard ERP protocol, MBCT-OCD adapted the psychoeducational components of the standard MBCT for depression protocol to suit OCD, but without explicit ERP tasks. Three common main themes emerged across MB-ERP and MBCT-OCD: 'satisfaction with course features', 'acceptability of key therapeutic tasks 'and 'using mindfulness to respond differently to OCD'. Sub-themes identified under the first two main themes were mostly unique to MB-ERP or MBCT-OCD, with the exception of '(struggles with) developing a mindfulness practice routine' whilst most of the sub-themes under the last main theme were shared across MB-ERP and MBCT-OCD participants. Findings suggested that participants generally perceived both MBIs as acceptable and potentially beneficial treatments for OCD, in line with theorised mechanisms of change., Competing Interests: CS is Research Lead for Sussex Mindfulness Centre and has received NIHR and other research funding to evaluate mindfulness-based interventions. TL, KC, LL, CR, AMJ and EF have received research funding to evaluate mindfulness-based interventions.

Background: Post-traumatic stress disorder (PTSD) is a severe and disabling condition that may lead to functional impairment and reduced productivity. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost-effectiveness of a range of interventions for adults with PTSD., Methods: A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of 10 interventions and no treatment for adults with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion., Results: Eye movement desensitisation and reprocessing (EMDR) appeared to be the most cost-effective intervention for adults with PTSD (with a probability of 0.34 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by combined somatic/cognitive therapies, self-help with support, psychoeducation, selective serotonin reuptake inhibitors (SSRIs), trauma-focused cognitive behavioural therapy (TF-CBT), self-help without support, non-TF-CBT and combined TF-CBT/SSRIs. Counselling appeared to be less cost-effective than no treatment. TF-CBT had the largest evidence base., Conclusions: A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR appears to be the most cost-effective amongst them. TF-CBT has the largest evidence base. There remains a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of treatments for adults with PTSD., Competing Interests: IM, OMV, SS and SP received support from the National Collaborating Centre for Mental Health and the National Guideline Alliance, which were in receipt of funding from the National Institute for Health and Care Excellence (NICE), for the submitted work. CD, SD and NJW received support from the NICE Guidelines Technical Support Unit, University of Bristol, with funding from the Centre for Clinical Practice (NICE). SD and NJW were co-applicants on a grant (unrelated to this work) from the MRC Methodology Research Programme which included an MRC Industry Collaboration Agreement with Pfizer Ltd, who part-funded a researcher to work on statistical methodology in a project underlated to this work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. GB is a coinvestigator on a NIHR RfPB grant, Eye Movement Desensitization and Reprocessing Therapy in Early Psychosis (EYES): A feasibility randomised controlled trial. NGreenberg is the Royal College of Psychiatrists Lead for Military and Veterans’ Health and is a trustee of two military charities. He is also a senior researcher with King’s College London working on a number of military mental health r studies. NGrey is a member of the Wellcome Trust Anxiety Disorders Group developing, testing and disseminating Cognitive Therapy for PTSD (CT-PTSD), a trauma-focused cognitive behavioural therapy (TF-CBT). He has published papers and book chapters on CT-PTSD, and facilitates teaching workshops for which payment is received. As editor, he receives royalties from sales of a trauma book, A Casebook of Cognitive Therapy for Traumatic Stress Reactions. CK is Medical Director of the Helen Bamber Foundation (a human rights charity) and refugee and asylum mental health lead for the Royal College of Psychiatrists. He writes expert psychiatric reports in the context of asylum mental health. JL is NHS England Medical Director for Military and Veterans Health. SP receives funding from NICE for the development of clinical guidelines and is also supported by the NIHR UCLH Biomedical Research Centre. The authors report no other relationships or activities that could appear to have influenced the submitted work.

Background and Objectives: Agitation is common in people living with dementia especially at the end of life. We examined how staff interpreted agitation behavior in people with dementia nearing end of life, how this may influence their responses and its impact on the quality of care., Research Design: Ethnographic study. Structured and semi-structured non-participant observations (referred to subsequently in this paper as "structured observations") of people living with dementia nearing the end of life in hospital and care homes (south-east England) and in-depth interviews with staff, conducted August 2015-March 2017., Methods: Three data sources: 1) detailed field notes, 2) observations using a structured tool and checklist for behaviors classed as agitation and staff and institutional responses, 3) staff semi-structured qualitative interviews. We calculated the time participants were agitated and described staff responses. Data sources were analyzed separately, developed continuously and relationally during the study and synthesized where appropriate., Results: We identified two main 'ideal types' of staff explanatory models for agitation: In the first, staff attribute agitated behaviors to the person's "moral judgement", making them prone to rejecting or punitive responses. In the second staff adopt a more "needs-based" approach in which agitation behaviors are regarded as meaningful and managed with proactive and investigative approaches. These different approaches appear to have significant consequences for the timing, frequency and quality of staff response. While these models may overlap they tend to reflect distinct organizational resources and values., Conclusions: Care worker knowledge about agitation is not enough, and staff need organizational support to care better for people living with dementia towards end of life. Positional theory may help to explain much of the cultural-structural context that produces staff disengagement from people with dementia, offering insights on how agitation behavior is reframed by some staff as dangerous. Such behavior may be associated with low-resource institutions with minimal staff training where the personhood of staff may be neglected., Competing Interests: The authors have declared that no competing interests exist.

The importance of accounting for social and behavioural processes when studying public health emergencies has been well-recognised. For infectious disease outbreaks in particular, several methods of incorporating individual behaviour have been put forward, but very few are based on established psychological frameworks. In this paper, we develop a decision framework based on the COM-B model of behaviour change to investigate the impact of individual decision-making on public health outcomes. We demonstrate the application of our decision framework in a proof-of-concept case study based on the 2009 A(H1N1) influenza pandemic in the UK. The National Pandemic Flu Service (NPFS) was set up in England during the pandemic as a means to provide antiviral (AV) treatment to clinically ill patients with influenza-like illness, via telephone calls or internet screening, thereby averting the need to see a doctor. The evaluated patients based on a clinical algorithm and authorised AV drugs for collection via community collection points. We applied our behavioural framework to evaluate the influence of human behaviour on AV collection rates, and subsequently to identify interventions that could help improve AV collection rates. Our model was validated against empirically collected pandemic data from 2009 in the UK. We also performed a sensitivity analysis to identify potentially effective interventions by varying model parameters. Using our behavioural framework in a proof-of-concept case study, we found that interventions geared towards increasing people's 'Capability' and 'Opportunity' are likely to result in increased AV collection, potentially resulting in fewer influenza-related hospitalisations and deaths. We note that important behavioural data from public health emergencies are largely scarce. Insights obtained from models such as ours can, not only be very useful in designing healthcare interventions, but also inform future data collection., Competing Interests: SV and JSN-V-T are currently working on outputs from the PRIDE study which is supported by an unrestricted educational grant from F. Hoffman La Roche. F. Hoffman La Roche had no role in any aspect of this study. JSN-V-T reports grants from F. Hoffmann-La Roche, personal fees from Shionogi Ltd. (in 2016) outside the submitted work; he is currently on secondment from the University of Nottingham to the Department of Health and Social Care (England). The work and conclusions presented here are those of the authors and do not necessarily represent the official position of the Department of Health and Social Care (England). P-OS and SV reports no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

The environment receives antibiotics through a combination of direct application (e.g., aquaculture and fruit production), as well as indirect release through pharmaceutical manufacturing, sewage and animal manure. Antibiotic concentrations in many sewage-impacted rivers are thought to be sufficient to select for antibiotic resistance genes. Yet, because antibiotics are nearly always found associated with antibiotic-resistant faecal bacteria in wastewater, it is difficult to distinguish the selective role of effluent antibiotics within a 'sea' of gut-derived resistance genes. Here we examine the potential for macrolide and fluoroquinolone prescribing in England to select for resistance in the River Thames catchment, England. We show that 64% and 74% of the length of the modelled catchment is chronically exposed to putative resistance-selecting concentrations (PNEC) of macrolides and fluoroquinolones, respectively. Under current macrolide usage, 115 km of the modelled River Thames catchment (8% of total length) exceeds the PNEC by 5-fold. Similarly, under current fluoroquinolone usage, 223 km of the modelled River Thames catchment (16% of total length) exceeds the PNEC by 5-fold. Our results reveal that if reduced prescribing was the sole mitigating measure, that macrolide and fluoroquinolone prescribing would need to decline by 77% and 85%, respectively, to limit resistance selection in the catchment. Significant reductions in antibiotic prescribing are feasible, but innovation in sewage-treatment will be necessary for achieving substantially-reduced antibiotic loads and inactivation of DNA-pollution from resistant bacteria. Greater confidence is needed in current risk-based targets for antibiotics, particularly in mixtures, to better inform environmental risk assessments and mitigation., Competing Interests: Andrew Singer status as Academic Editor for PLOS ONE and handling editor in the Antimicrobial Resistance call for papers does not alter our adherence to PLOS ONE policies on sharing data and materials

Given the centrality of regions in social movements, politics and public administration, here we aim to quantitatively study regional identity, cross-region communication and sentiment. This paper presents a new methodology to study social interaction within and between social-geographic regions, and then applies the methodology to a case study of England and Wales. We use a social network, built from geo-located Twitter data, to identify contiguous geographical regions with a shared social identity and then investigate patterns of communication within and between them. In contrast to other approaches (e.g. using phone call data records or online friendship networks), use of Twitter data provides message contents as well as social connections. This allows us to investigate not only the volume of communication between locations, but also the sentiment and vocabulary used in the messages. For example, our case study shows: a significant dialect difference between England and Wales; that regions tend to be more positive about themselves than about others, with the South being more 'self-regarding' than the North; and that people talk politics much more between regions than within. This study demonstrates how social media can be used to quantify regional identity and inter-region communications and sentiment, exposing these previously hard-to-observe geographic concepts to analysis., Competing Interests: The authors have declared that no competing interests exist.

Background: Centile curves and standard scores are common in epidemiological research. However, standardised norms and centile growth curves for language disorder that reflect the entire UK local school population do not exist., Methods: Scores on six language indices assessing receptive and expressive functioning of children were obtained from the SCALES population survey. Monolingual English speaking participants were aged between five and nine years. Children who attended special schools at study intake, or who were learning English as an additional language were excluded. We constructed language norms using the LMS method of standardisation which allows for skewed measurements. We made use of probability weights that were produced from a two-step logistic model. Distributions of estimated standard scores from an intensively assessed sub-population and from the full population were contrasted to demonstrate the role of weights., Results: Non-overlapping centile curves and standardised scores at each age were obtained for the six language indices. The use of weights was essential at retrieving the target distribution of the scores. An online calculator that estimates standardised scores for the measures was constructed and made freely available., Conclusions: The findings highlight the usefulness and flexibility of the LMS method at dealing with the standardisation of linguistic and educational measures that are sufficiently continuous. The paper adds to the existing literature by providing population norms for a number of language tests that were calculated from the same group of individuals., Competing Interests: The authors have declared that no competing interests exist.

Earthworms are primary candidates for national soil health monitoring as they are ecosystem engineers that benefit both food production and ecosystem services associated with soil security. Supporting farmers to monitor soil health could help to achieve the policy aspiration of sustainable soils by 2030 in England; however, little is known about how to overcome participation barriers, appropriate methodologies (practical, cost-effective, usefulness) or training needs. This paper presents the results from a pilot #60minworms study which mobilised farmers to assess over >1300 ha farmland soils in spring 2018. The results interpretation framework is based on the presence of earthworms from each of the three ecological groups at each observation (20 x 20 cm x 20 cm pit) and spatially across a field (10 soil pits). Results showed that most fields have basic earthworm presence and abundance, but 42% fields may be over-worked as indicated by absence/rarity of epigeic and/or anecic earthworms. Tillage had a negative impact (p < 0.05) on earthworm populations and organic matter management did not mitigate tillage impacts. In terms of farmer participation, Twitter and Farmers Weekly magazine were highly effective channels for recruitment. Direct feedback from participants included excellent scores in trust, value and satisfaction of the protocol (e.g. 100% would do the test again) and 57% would use their worm survey results to change their soil management practices. A key training need in terms of earthworm identification skills was reported. The trade-off between data quality, participation rates and fieldwork costs suggests there is potential to streamline the protocol further to #30minworms (5 pits), incurring farmer fieldwork costs of approximately £1.48 ha-1. At national scales, £14 million pounds across 4.7 M ha-1 in fieldwork costs per survey could be saved by farmer participation., Competing Interests: The author has declared that no competing interests exist.

In 2010, the UK embarked on a self-imposed programme of contractionary measures signalling the beginning of a so-called "age of austerity" for the country. It was argued that budgetary cuts were the most appropriate means of eliminating deficits and decreasing national debt as percentage of General Domestic Product (GDP). Although the budget for the National Health Service (NHS) was not reduced, a below-the-average increase in funding, and cuts in other areas of public spending, particularly in social care and welfare spending, impacted significantly on the NHS. One of the areas where the impact of austerity was most dramatically felt was in Accidents and Emergency Departments (A&E). A number of economic and statistical reports and quantitative studies have explored and documented the effects of austerity in healthcare in the UK, but there is a paucity of research looking at the effects of austerity from the standpoint of the healthcare professionals. In this paper, we report findings from a qualitative study with healthcare professionals working in A&E departments in England. The study findings are presented thematically in three sections. The main theme that runs through all three sections is the perceptions of austerity as shaping the functioning of A&E departments, of healthcare professions and of professionals themselves. The first section discusses the rising demand for services and resources, and the changed demographic of A&E patients-altering the meaning of A&E from 'Accidents and Emergencies' to the Department for 'Anything and Everything'. The second section in this study's findings, explores how austerity policies are perceived to affect the character of healthcare in A&E. It discusses how an increased focus on the procedures, time-keeping and the operationalisation of healthcare is considered to detract from values such as empathy in interactions with patients. In the third section, the effects of austerity on the morale and motivations of healthcare professionals themselves are presented. Here, the concepts of moral distress and burnout are used in the analysis of the experiences and feelings of being devalued. From these accounts and insights, we analyse austerity as a catalyst or mechanism for a significant shift in the practice and function of the NHS-in particular, a shift in what is counted, measured and valued at departmental, professional and personal levels in A&E., Competing Interests: The authors have declared that no competing interests exist.

Economic cycles may lead to changes in corporate bond credit ratings. This paper utilizes the Markov model to describe transition probability matrixes of economic states for the separation of economic cycles. We develop a new model, which we term the Markov rating shopping dual reputation model, incorporating two reputation effects. This model is well suited to analyze the conditions of the dual rating incentive regulation and the constraint regulation for preventing rating inflation in collusion among credit rating agencies. Then, we apply the Markov regime switching-vector auto-regression (MS-VAR) to estimate the transition probability matrixes of America, England, Japan and China. Based on the numerical analysis and the simulations, the results show that a dual rating regulation can prevent the collusion of inflated ratings, as well as increased rating fees with the separation of economic cycles; additionally, when separating the economic cycles, a constraint regulation is more effective at reducing the risk of rating inflation in collusion and regulatory cost., Competing Interests: PZ is an employee of Purdue Technology Company Ltd of Shenzhen. This does not alter our adherence to PLOS ONE policies on sharing data and materials. All other authors declare no competing interests exist.

This paper examines the association between given and family names and self-ascribed ethnicity as classified by the 2011 Census of Population for England and Wales. Using Census data in an innovative way under the new Office for National Statistics (ONS) Secure Research Service (SRS; previously the ONS Virtual Microdata Laboratory, VML), we investigate how bearers of a full range of given and family names assigned themselves to 2011 Census categories, using a names classification tool previously described in this journal. Based on these results, we develop a follow-up ethnicity estimation tool and describe how the tool may be used to observe changing relations between naming practices and ethnic identities as a facet of social integration and cosmopolitanism in an increasingly diverse society., Competing Interests: The authors have declared that no competing interests exist.

Smoking has been identified as the second greatest risk factor for global death and disability and has impacts on the oral cavity from aesthetic changes to fatal diseases such as oral cancer. The paper presents a secondary analysis of the National Adult Dental Health Survey (2009). The analysis used descriptive statistics, bivariate analyses and logistic regression models to report the self-reported oral health status and dental attendance of smokers and non-smokers in England. Of the 9,657 participants, 21% reported they were currently smoking. When compared with smokers; non-smokers were more likely to report 'good oral health' (75% versus 57% respectively, p<0.05). Smokers were twice as likely to attend the dentist symptomatically (OR = 2.27, CI = 2.02-2.55) compared with non-smoker regardless the deprivation status. Smokers were more likely to attend symptomatically in the most deprived quintiles (OR = 1.99, CI = 1.57-2.52) and perceive they had poorer oral health (OR = 1.77, CI = 1.42-2.20). The present research is consistent with earlier sub-national research and should be considered when planning early diagnosis and management strategies for smoking-related conditions, considering the potential impact dental teams might have on smoking rates.

Background: The Enhanced Matching System (EMS) is a probabilistic record linkage program developed by the tuberculosis section at Public Health England to match data for individuals across two datasets. This paper outlines how EMS works and investigates its accuracy for linkage across public health datasets., Methods: EMS is a configurable Microsoft SQL Server database program. To examine the accuracy of EMS, two public health databases were matched using National Health Service (NHS) numbers as a gold standard unique identifier. Probabilistic linkage was then performed on the same two datasets without inclusion of NHS number. Sensitivity analyses were carried out to examine the effect of varying matching process parameters., Results: Exact matching using NHS number between two datasets (containing 5931 and 1759 records) identified 1071 matched pairs. EMS probabilistic linkage identified 1068 record pairs. The sensitivity of probabilistic linkage was calculated as 99.5% (95%CI: 98.9, 99.8), specificity 100.0% (95%CI: 99.9, 100.0), positive predictive value 99.8% (95%CI: 99.3, 100.0), and negative predictive value 99.9% (95%CI: 99.8, 100.0). Probabilistic matching was most accurate when including address variables and using the automatically generated threshold for determining links with manual review., Conclusion: With the establishment of national electronic datasets across health and social care, EMS enables previously unanswerable research questions to be tackled with confidence in the accuracy of the linkage process. In scenarios where a small sample is being matched into a very large database (such as national records of hospital attendance) then, compared to results presented in this analysis, the positive predictive value or sensitivity may drop according to the prevalence of matches between databases. Despite this possible limitation, probabilistic linkage has great potential to be used where exact matching using a common identifier is not possible, including in low-income settings, and for vulnerable groups such as homeless populations, where the absence of unique identifiers and lower data quality has historically hindered the ability to identify individuals across datasets.

Objectives: Including questions about sexual health in the annual Health Survey for England (HSE) provides opportunities for regular measurement of key public health indicators, augmenting Britain's decennial National Survey of Sexual Attitudes and Lifestyles (Natsal). However, contextual and methodological differences may limit comparability of the findings. We examine the extent of these differences between HSE 2010 and Natsal-3 and investigate their impact on parameter estimates., Methods: Complex survey analyses of data from men and women in the 2010 HSE (n = 2,782 men and 3,588 women) and Natsal-3 undertaken 2010-2012 (n = 4,882 men and 6,869 women) aged 16-69y and resident in England, both using probability sampling, compared their characteristics, the amount of non-response to, and estimates from, sexual health questions. Both surveys used self-completion for the sexual behaviour questions but this was via computer-assisted self-interview (CASI) in Natsal-3 and a pen-and-paper questionnaire in HSE 2010., Results: The surveys achieved similar response rates, both around 60%, and demographic profiles largely consistent with the census, although HSE participants tended to be less educated, and reported worse general health, than Natsal-3 participants. Item non-response to the sexual health questions was typically higher in HSE 2010 (range: 9-18%) relative to Natsal-3 (all <5%). Prevalence estimates for sexual risk behaviours and STI-related indicators were generally slightly lower in HSE 2010 than Natsal-3., Conclusions: While a relatively high response to sexual health questions in HSE 2010 demonstrates the feasibility of asking such questions in a general health survey, differences with Natsal-3 do exist. These are likely due to the HSE's context as a general health survey and methodological limitations such as its current use of pen-and-paper questionnaires. Methodological developments to the HSE should be considered so that its data can be interpreted in combination with those from dedicated sexual health surveys, thus improving our ability to monitor trends in sexual health.

Purpose: Harmful alcohol consumption among the ageing population is an important public health issue. Very few studies ask drinkers why they change their consumption in later life. The aim of this paper was to determine whether a group of people aged over 60 years increased or decreased their alcohol consumption over the past decade and to determine the reasons for their change. We also examined whether the responses varied by age, sex and socio-economic position (SEP)., Subjects and Methods: Data were taken from 6,011 participants (4,310 men, 1,701 women, age range 61 to 85 years) who completed questionnaires at phase 11 (2012-2013) of the Whitehall II Cohort Study., Results: Over half the study members reported a change in alcohol consumption over the past decade (40% decreased, 11% increased). The most common reasons given for decreases were as a health precaution and fewer social occasions. Common reasons for increases were more social occasions and fewer responsibilities. The lowest SEP group was less likely to increase consumption compared to high SEP (RR 0.57, 95% CI 0.40 to 0.81). Women were more likely to increase consumption in response to stress/depression than men (RR1.53, 95% CI 1.04 to 2.25). Compared to high SEP, the lowest SEP group was less likely to reduce as a health precaution (RR 0.61, 95% CI 0.38 to 0.76)., Conclusions: Alcohol consumption in late life is not fixed. Reasons for change vary by age, sex and SEP. Such information could be used to tailor intervention strategies to reduce harmful consumption.

Background: There are conflicting views as to whether childhood wheezing represents several discreet entities or a single but variable disease. Classification has centered on phenotypes often derived using subjective criteria, small samples, and/or with little data for young children. This is particularly problematic as asthmatic features appear to be entrenched by age 6/7. In this paper we aim to: identify longitudinal trajectories of wheeze and other atopic symptoms in early childhood; characterize the resulting trajectories by the socio-economic background of children; and identify potentially modifiable processes in infancy correlated with these trajectories., Data and Methods: The Millennium Cohort Study is a large, representative birth cohort of British children born in 2000-2002. Our analytical sample includes 11,632 children with data on key variables (wheeze in the last year; ever hay-fever and/or eczema) reported by the main carers at age 3, 5 and 7 using a validated tool, the International Study of Asthma and Allergies in Childhood module. We employ longitudinal Latent Class Analysis, a clustering methodology which identifies classes underlying the observed population heterogeneity., Results: Our model distinguished four latent trajectories: a trajectory with both low levels of wheeze and other atopic symptoms (54% of the sample); a trajectory with low levels of wheeze but high prevalence of other atopic symptoms (29%); a trajectory with high prevalence of both wheeze and other atopic symptoms (9%); and a trajectory with high levels of wheeze but low levels of other atopic symptoms (8%). These groups differed in terms of socio-economic markers and potential intervenable factors, including household damp and breastfeeding initiation., Conclusion: Using data-driven techniques, we derived four trajectories of asthmatic symptoms in early childhood in a large, population based sample. These groups differ in terms of their socio-economic profiles. We identified correlated intervenable pathways in infancy, including household damp and breastfeeding initiation.

In this paper we analyse the word frequency profiles of a set of works from the Shakespearean era to uncover patterns of relationship between them, highlighting the connections within authorial canons. We used a text corpus comprising 256 plays and poems from the 16th and 17th centuries, with 17 works of uncertain authorship. Our clustering approach is based on the Jensen-Shannon divergence and a graph partitioning algorithm, and our results show that authors' characteristic styles are very powerful factors in explaining the variation of word use, frequently transcending cross-cutting factors like the differences between tragedy and comedy, early and late works, and plays and poems. Our method also provides an empirical guide to the authorship of plays and poems where this is unknown or disputed.

Objectives: Increasing walking and cycling, and reducing motorised transport, are health and environmental priorities. This paper examines levels and trends in the use of different commute modes in England and Wales, both overall and with respect to small-area deprivation. It also investigates whether commute modal share can serve as a proxy for travel behaviour more generally., Methods: 23.7 million adult commuters reported their usual main mode of travelling to work in the 2011 census in England and Wales; similar data were available for 1971-2001. Indices of Multiple Deprivation were used to characterise socio-economic patterning. The National Travel Survey (2002-2010) was used to examine correlations between commute modal share and modal share of total travel time. These correlations were calculated across 150 non-overlapping populations defined by region, year band and income., Results: Among commuters in 2011, 67.1% used private motorised transport as their usual main commute mode (-1.8 percentage-point change since 2001); 17.8% used public transport (+1.8% change); 10.9% walked (-0.1% change); and 3.1% cycled (+0.1% change). Walking and, to a marginal extent, cycling were more common among those from deprived areas, but these gradients had flattened over the previous decade to the point of having essentially disappeared for cycling. In the National Travel Survey, commute modal share and total modal share were reasonably highly correlated for private motorised transport (r = 0.94), public transport (r = 0.96), walking (r = 0.88 excluding London) and cycling (r = 0.77)., Conclusions: England and Wales remain car-dependent, but the trends are slightly more encouraging. Unlike many health behaviours, it is more common for socio-economically disadvantaged groups to commute using physically active modes. This association is, however, weakening and may soon reverse for cycling. At a population level, commute modal share provides a reasonable proxy for broader travel patterns, enhancing the value of the census in characterising background trends and evaluating interventions.

Objectives: To extend existing research on the US health disadvantage relative to Europe by studying the relationships of disability with age from midlife to old age in the US and four European regions (England/Northern and Western Europe/Southern Europe/Eastern Europe) including their wealth-related differences, using a flexible statistical approach to model the age-functions., Methods: We used data from three studies on aging, with nationally representative samples of adults aged 50 to 85 from 15 countries (N = 48225): the US-American Health and Retirement Study (HRS), the English Longitudinal Study of Ageing (ELSA) and the Survey of Health, Ageing and Retirement in Europe (SHARE). Outcomes were mobility limitations and limitations in instrumental activities of daily living. We applied fractional polynomials of age to determine best fitting functional forms for age on disability in each region, while controlling for socio-demographic characteristics and important risk factors (hypertension, diabetes, obesity, smoking, physical inactivity)., Results: Findings showed high levels of disability in the US with small age-related changes between 50 and 85. Levels of disability were generally lower in Eastern Europe, followed by England and Southern Europe and lowest in Northern and Western Europe. In these latter countries age-related increases of disability, though, were steeper than in the US, especially in Eastern and Southern Europe. For all countries and at all ages, disability levels were higher among adults with low wealth compared to those with high wealth, with largest wealth-related differences among those in early old age in the USA., Conclusions: This paper illustrates considerable variations of disability and its relationship with age. It supports the hypothesis that less developed social policies and more pronounced socioeconomic inequalities are related to higher levels of disability and an earlier onset of disability.

Background: Imperfect diagnostic testing reduces the power to detect significant predictors in classical cross-sectional studies. Assuming that the misclassification in diagnosis is random this can be dealt with by increasing the sample size of a study. However, the effects of imperfect tests in longitudinal data analyses are not as straightforward to anticipate, especially if the outcome of the test influences behaviour. The aim of this paper is to investigate the impact of imperfect test sensitivity on the determination of predictor variables in a longitudinal study., Methodology/principal Findings: To deal with imperfect test sensitivity affecting the response variable, we transformed the observed response variable into a set of possible temporal patterns of true disease status, whose prior probability was a function of the test sensitivity. We fitted a Bayesian discrete time survival model using an MCMC algorithm that treats the true response patterns as unknown parameters in the model. We applied our approach to epidemiological data of bovine tuberculosis outbreaks in England and investigated the effect of reduced test sensitivity in the determination of risk factors for the disease. We found that reduced test sensitivity led to changes to the collection of risk factors associated with the probability of an outbreak that were chosen in the 'best' model and to an increase in the uncertainty surrounding the parameter estimates for a model with a fixed set of risk factors that were associated with the response variable., Conclusions/significance: We propose a novel algorithm to fit discrete survival models for longitudinal data where values of the response variable are uncertain. When analysing longitudinal data, uncertainty surrounding the response variable will affect the significance of the predictors and should therefore be accounted for either at the design stage by increasing the sample size or at the post analysis stage by conducting appropriate sensitivity analyses.

Background: Public health provision in England is undergoing dramatic changes. Currently established partnerships are thus likely to be significantly disrupted by the radical reforms outlined in the Public Health White Paper. We therefore explored the process of partnership working in public health, in order to better understand the potential opportunities and threats associated with the proposed changes., Methodology/principal Findings: 70 participants took part in an in-depth qualitative study involving 40 semi-structured interviews and three focus group discussions. Participants were senior and middle grade public health decision makers working in Primary Care Trusts, Local Authorities, Department of Health, academia, General Practice and Hospital Trusts and the third sector in England. Despite mature arrangements for partnership working in many areas, and much support for joint working in principle, many important barriers exist. These include cultural issues such as a lack of shared values and language, the inherent complexity of intersectoral collaboration for public health, and macro issues including political and resource constraints. There is particular uncertainty and anxiety about the future of joint working relating to the availability and distribution of scarce and diminishing financial resources. There is also the concern that existing effective collaborative networks may be completely disrupted as the proposed changes unfold. The extent to which the proposed reforms might mitigate or potentiate these issues remains unclear. However the threats currently remain more salient than opportunities., Conclusions: The current re-organisation of public health offers real opportunity to address some of the barriers to partnership working identified in this study. However, significant threats exist. These include the breakup of established networks, and the risk of cost cutting on effective public health interventions.

Estimating the age-specific incidence of an emerging pathogen is essential for understanding its severity and transmission dynamics. This paper describes a statistical method that uses likelihoods to estimate incidence from sequential serological data. The method requires information on seroconversion intervals and allows integration of information on the temporal distribution of cases from clinical surveillance. Among a family of candidate incidences, a likelihood function is derived by reconstructing the change in seroprevalence from seroconversion following infection and comparing it with the observed sequence of positivity among the samples. This method is applied to derive the cumulative and weekly incidence of A/H1N1 pandemic influenza in England during the second wave using sera taken between September 2009 and February 2010 in four age groups (1-4, 5-14, 15-24, 25-44 years). The highest cumulative incidence was in 5-14 year olds (59%, 95% credible interval (CI): 52%, 68%) followed by 1-4 year olds (49%, 95% CI: 38%, 61%), rates 20 and 40 times higher respectively than estimated from clinical surveillance. The method provides a more accurate and continuous measure of incidence than achieved by comparing prevalence in samples grouped by time period.