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Healthcare services for people living with dementia (PLWD) are stretched, and government promises of increased funding remain undelivered. With the UK dementia population to surpass 1 million by 2024, and dementia care costs predicted to almost treble by 2040, it is essential we understand differences in healthcare use among PLWD. This study aimed to explore social and spatial variations in healthcare use among people diagnosed with dementia (2002–2016). Data were derived from Electronic Health Records of Clinical Practice Research Datalink GP patients in England (n = 142,302). To standardise healthcare contacts, rates of healthcare contacts per year were calculated for three primary (GP observations and medications) and three secondary healthcare types [Accident & Emergency (A&E) attendances and, emergency and elective hospital admissions]. Fully-adjusted generalised linear regression models were used to identify healthcare use variation by social and spatial groups. Twelve models were generated, one for each healthcare type in early- and late-onset populations separately. This study highlights numerous social and spatial variations in healthcare use among PLWD. Among PLWD, several groups tended to have healthcare service use more closely associated with negative outcomes, including a greater likelihood of A&E attendances and emergency and elective hospital admissions. These groups include: men, people from White ethnicity groups and people from more deprived and rural areas. Systemic and social measures are needed to reduce variations in healthcare use inequalities in PWLD. These include greater healthcare continuity, health checks and medicines reviews, culturally appropriate services, better and more accessible treatment and improved infrastructure. [ABSTRACT FROM AUTHOR]

Shellfish mariculture, the farming of marine bivalve shellfish, is a highly sustainable form of food production, which contributes significantly to the rural, coastal economies of England and Wales, and has considerable potential for growth. To unlock this potential, we explored the application of the positive tipping points (PTP) framework in an invited stakeholder workshop comprising key policy makers, regulators, industry representatives and academic researchers. Stakeholders mapped environmental and socio-economic factors constraining shellfish mariculture and identified key opportunities (leverage points) for positive intervention. The workshop focused on five case studies from southwest England addressing key constraints identified for the shellfish industry, including "licencing", "spatial planning" and/or "classification" of shellfish sites and cultured species. These case studies presented new data on the effectiveness of a range of interventions: i) catchment scale, and ii) nature-based, solutions for water quality management in the Exe estuary; iii) risk-based methods for assuring shellfish quality/safety in the Camel estuary; iv) evidence gathering on ecosystem services (habitat provisioning) by shellfish mariculture in Lyme Bay and, v) policy developments on licencing of Pacific oysters in England. Stakeholders highlighted opportunities for new guidance, innovative tools and technology to aid environmental monitoring, regulation and quality assurance for shellfish mariculture and for tradeable ecosystem services beyond food production (including nutrient regulation, coastal protection and habitat provisioning). These and other interventions identified by stakeholders (including product diversification and market development) were then prioritised and sequenced for optimal implementation. Actions, actors and enabling conditions were identified using the PTP framework to realise prioritised opportunities. [Display omitted]. • Application of the PTP framework was explored for promoting sustainable growth in shellfish mariculture in England and Wales. • Environmental and socio-economic constraints to sustainable growth were identified in a multi-stakeholder workshop. • These included classification and licencing of mariculture sites and species, impaired water quality and restricted markets. • Interventions with the potential to promote multiple positive ecological and social-ecological feedbacks were prioritised. • These included valuation of ecosystem services e.g. habitat provision by mariculture for marine conservation and fisheries. [ABSTRACT FROM AUTHOR]

Background and Aims In many countries, conflicting gradients in alcohol consumption and alcohol-associated mortality have been observed. To understand this 'alcohol harm paradox' we analysed the socio-economic gradient in alcohol-associated hospital admissions to test whether it was greater in conditions which were: (1) chronic (associated with long-term drinking) and partially alcohol-attributable, (2) chronic and wholly alcohol-attributable, (3) acute (associated with intoxication) and partially alcohol-attributable and (4) acute and wholly alcohol-attributable. Our aim was to clarify how (1) drinking patterns (e.g. intoxication linked to acute admissions or dependence linked to chronic conditions) and (2) non-alcohol causes (e.g. smoking and poor diet which are risks for partially alcohol-attributable conditions) contribute to the paradox. Design Regression analysis testing the modifying effects of condition-group (1-4 above) and sex on the relationship between area-based deprivation and admissions. Setting England, April 2010-March 2013. Participants A total of 9 239 629 English hospital admissions where a primary or secondary cause was one of 36 alcohol-associated conditions. Measurements Admissions by condition and deciles of Index of Multiple Deprivation (IMD). Socio-economic gradient measured as the relative index of inequality (RII, the slope of a linear regression of IMD on admissions adjusted for overall admission rate). Conditions were categorized by ICD-10 code. Findings A socio-economic gradient in hospitalizations was seen for all conditions, except partially attributable chronic conditions. The gradient was significantly steeper for conditions which were wholly attributable to alcohol and for acute conditions than for conditions partially alcohol-attributable and for chronic conditions. Gradients were steeper for men than for women in cases of wholly alcohol attributable conditions. Conclusions There is a socio-economic gradient in English hospital admission for most alcohol-associated conditions. The greatest inequalities are in conditions associated with alcohol dependence, such as liver disease and mental and behavioural conditions, and in acute conditions, such as alcohol poisoning and assault. Socio-economic differences in harmful drinking patterns (dependence and intoxication) may contribute to the 'alcohol harm paradox'. [ABSTRACT FROM AUTHOR]

Objective: The objective of this analysis was to explore the healthcare-seeking behaviours and experiences of maternity care among women from different socio-economic groups in order to improve understanding of why socially disadvantaged women have poorer maternal health outcomes in the UK.Design: Secondary analysis of a national survey of women conducted 3 months after they had given birth.Setting: England.Sample: A total of 5332 women.Methods: Logistic regression analysis to investigate differences in outcomes among different socio-economic groups, classified by the Index of Multiple Deprivation (IMD).Main Outcome Measures: Healthcare-seeking behaviours, outcomes and experiences of maternity care.Results: With each increase in IMD quintile (decrease in socio-economic position), women were shown to be 25% (adjusted odds ratio [aOR] 0.75; 95% confidence interval [95% CI] 0.63-0.90) less likely to have had any antenatal care and 15% (aOR 0.85; 95% CI 0.80-0.90) less likely to have had a routine postnatal check-up. They were 4% (aOR 1.04; 95% CI 0.99-1.10) more likely to have had an antenatal hospital admission, 7% (aOR 1.07; 95% CI 0.99-1.16) more likely to have been transferred during labour and 4% (aOR 1.04; 95% CI 0.99-1.09) more likely to have had a caesarean birth, although these results were not statistically significant. With decreasing socio-economic position women were more likely to report that they were not treated respectfully or spoken to in a way they could understand by doctors and midwives.Conclusions: This analysis suggests the need for a focusing of professionals and services towards pregnant women from lower socio-economic groups and more targeted maternal public health education towards socially disadvantaged women. [ABSTRACT FROM AUTHOR]

One of the most consistent and worrying features of the COVID-19 pandemic globally has been the disproportionate burden of the epidemic in the most deprived areas. Most of the literature so far though has focused on estimating the extent of these inequalities. There has been much less attention paid to exploring the main pathways underpinning them. In this study, we employ the syndemic pandemic theoretical framework and apply novel decomposition methods to investigate the proportion of the COVID-19 mortality gap by area-level deprivation in England during the first wave of the pandemic (January to July 2020) was accounted for by pre-existing inequalities in the compositional and contextual characteristics of place. We use a decomposition approach to explicitly quantify the independent contribution of four inequalities pathways (vulnerability, susceptibility, exposure and transmission) in explaining the more severe COVID-19 outcomes in the most deprived local authorities compared to the rest. We find that inequalities in transmission (73%) and in vulnerability (49%) factors explained the highest proportion of mortality by deprivation. Our results suggest that public health agencies need to develop short- and long-term strategies to alleviate these underlying inequalities in order to alleviate the more severe impacts on the most vulnerable communities. • Empirically examines the syndemic pandemic framework for inequalities in COVID-19. • PCA and Decomposition used to explore the pathways to inequalities in COVID-19. • Finds that area-level transmission and vulnerability factors are most important. • Considers the policy and research implications for health inequalities. [ABSTRACT FROM AUTHOR]

Background: Data for England from the national census can provide the socio-economic background of individual pupils and therefore the intake of schools. In many respects, this is more useful than the conventional measure of 'free school meals', which has historically been used in the UK as a proxy measure for disadvantage. Prior to the advent of the English Pupil-level Annual School Census in 2001, using census data for research concerning schools was problematic as the immediate location of the school is often socio-economically different to areas in which the pupils live. Now and in future, working with the national census is considerably more attractive as data on individual pupils can be matched and information aggregated to school level to provide measures that reflect intake rather than immediate location. Purpose: This paper discusses the details, merits and uses of this approach. It considers whether derived census data for England can replace or augment the traditional proxy measure for disadvantage, eligibility for free school meals. Sources of evidence: Statistical comparisons of derived data from the 2001 England national census and the free school meals measure were used to clarify strengths and weaknesses of the two approaches. A literature review concerning the measurement of socio-economic disadvantage for educational research provided background to the discussion. Educational researchers at the UK's National Foundation for Educational Research (NFER) provided details of what variables from the 2001 national census would be useful to derive. Data descriptions provided with the English Pupil-level Annual School Census and the 2001 England national census formed the basis of the data derivation. Main argument: Eligibility for free school meals has a number of problems when used as a proxy measure for disadvantage. The use of derived national census data to illustrate the socio-economic background of pupils and schools' intake is free of these problems. However, it has its own collection of setbacks that should determine how and when it is used. Conclusions: Derived national census data should be used in conjunction with eligibility for free school meals to enhance our knowledge of the important part background has to play in the education of children in England. [ABSTRACT FROM AUTHOR]

Objectives: To assess whether there is a relationship between smoking and levels of overall quality of life, or with the pleasure domain of quality of life, in Lower socio-economic groups (SES). Study design: Cohort study involving 9176 individuals aged 50 years and over who participated in the Health Survey for England and were followed up in Wave 1 of the English Longitudinal Study of Ageing in 2002. Methods: We classified smokers as never-smokers, ex-smokers and current smokers, and used household wealth as a marker for socio-economic position. Pleasure was assessed using the pleasure subscale of the CASP-19 instrument, a 19-point measure of quality of life that covers four theoretical domains: control, autonomy, self-realization and pleasure. Results: We found that the odds ratio for experiencing lower than median levels of pleasure for smokers with low SES was 1.42 (95% Cl 1.16-1.74), and for all smokers was 1.33 (95% Cl 1.17-1.51). The same pattern of associations was found when the outcome was total CASP-19 score or positive GHQ-12 score. Conclusions: We found no evidence to support a claim that smoking is associated with heightened levels of pleasure, either in people with low SES or in the general population. In fact, our results suggest the opposite: that smoking is associated with lower levels of pleasure and poorer overall quality of life. Policy decisions on smoking should consider its potentially harmful effect on quality of life and pleasure as well as on other aspects of health. [ABSTRACT FROM AUTHOR]

Objective To determine changes in childhood and parental asthma prevalence in Merseyside between 1991 and 1998. [ABSTRACT FROM PUBLISHER]

Background: Previous research has identified a relationship between income inequality and child abuse and neglect in the USA. This association has received limited exploration outside the USA., Methods: Administrative data on child protection (CP) in 172 English and Welsh local authorities between 2013 and 2018 were combined with data on deprivation, ethnic density and education from publicly available data sources. Commercial income data were used for Gini coefficient estimation. We tested whether similar evidence for three key findings from a US study could be found in England and Wales. These included whether there was evidence of a relationship between income inequality and child maltreatment, whether this relationship was non-linear and whether this relationship varied dependent on the level of poverty., Results: There was a significant non-linear relationship between income inequality and state care rates in England and Wales. Predicted state care rates were higher as income inequality increased, up until around average levels where the effect flattens. However, there was no significant relationship for models predicting CP plan/register rates. Income inequality, income deprivation, ethnic density and higher education were able to explain around 75% of the variance in English and Welsh state care rates., Conclusions: There is some evidence to support the claim of a relationship between income inequality and child maltreatment beyond the USA in England and Wales, and a case for further comparative research, but there are significant limitations in the comparability of data., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The increasing trends in opioid prescribing and opioid-related deaths in England are concerning. A greater understanding of the association of deprivation with opioid prescribing is needed to guide policy responses and interventions., Methods: The 2018/2019 English national primary care prescribing data were analysed spatially. Prescribing of opioids in general practice was quantified by defined daily doses (DDD) and attributed to 32 844 lower layer super output areas (LSOAs), the geographical units representing ~1500 people. Linear regression was used to model the effect of socioeconomic deprivation (quintiles) on opioid prescribing while accounting for population demographics and the prevalence of specific health conditions. Adjusted DDD estimates were compared at each deprivation level within higher organisational areas (Clinical Commissioning Groups, CCGs)., Results: In total, 624 411 164 DDDs of opioids were prescribed. LSOA-level prescribing varied between 1.7 and 121.04 DDD/1000 population/day. Prescribing in the most deprived areas in the North of England was 1.2 times higher than the national average for areas with similar deprivation levels and 3.3 times higher than the most deprived areas in London. Prescribing in the most deprived areas was on average 9.70 DDD/1000 people/day (95% CI 9.41 to 10.00) higher than the least deprived areas. Deprivation-driven disparities varied between individual CCGs. In the most unequal CCG, prescribing in the most deprived areas was twice that in the least deprived areas., Conclusion: Opioid prescribing varied substantially across England and deprivation was strongly associated with prescribing. This paper provides evidence for guiding policy interventions and allocation of resources to areas with the highest levels of opioid prescribing., Competing Interests: Competing interests: LCC and DMA have received funding for another study of opioid utilisation patterns from Mundipharma Research Ltd. MN, SSZ, RP, and EK have no conflict of interest to declare., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A large body of evidence documents the adverse relationship between concentrated deprivation and health. Among the evaluations of regeneration initiatives to tackle these spatial inequalities, few have traced the trajectories of individuals over time and fewer still have employed counterfactual comparison. We investigate the impact of one such initiative in England, the New Deal for Communities (NDC), which ran from 1999 to 2011, on socioeconomic inequalities in health trajectories., Methods: Latent Growth Curve modelling of within-person changes in self-rated health, mental health and life satisfaction between 2002 and 2008 of an analytical cohort of residents of 39 disadvantaged areas of England in which the NDC was implemented, compared with residents of comparator, non-intervention areas, focusing on: (1) whether differences over time in outcomes can be detected between NDC and comparator areas and (2) whether interventions may have altered socioeconomic differences in outcomes., Results: No evidence was found for an overall improvement in the three outcomes, or for significant differences in changes in health between respondents in NDC versus comparator areas. However, we found a weakly significant gap in life satisfaction and mental health between high and low socioeconomic status individuals in comparator areas which widened over time to a greater extent than in NDC areas. Change over time in the three outcomes was non-linear: individual improvements among NDC residents were largest before 2006., Conclusions: There is limited evidence that the NDC moderated the impact of socioeconomic factors on mental health and life satisfaction trajectories. Furthermore, any NDC impact was strongest in the first 6 years of the programmes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: The English NHS Bowel Cancer Screening Programme has offered biennial faecal occult blood testing to people aged 60-69 years since 2006, and to those aged 60-74 years since 2010. Analysis of the first 2.6 million screening invitations found that 54% of eligible people took up the invitation. The reasons for this low uptake are unclear. We investigated whether participation in screening varies according to cognitive ability and personality., Methods: Participants were members of The English Longitudinal Study of Ageing. In 2010-2011, respondents were asked about participation in bowel cancer screening, and cognitive ability and the 'Big Five' personality traits were assessed. Logistic regression was used to examine the cross-sectional relationships between cognitive ability and personality and screening participation in 2681 people aged 60-75 years who were eligible to have been invited to take part in the UK national screening programme for bowel cancer., Results: In age-adjusted and sex-adjusted analyses, better cognition and higher conscientiousness were associated with increased participation in cancer screening. ORs (95% CIs) per SD increase were 1.10 (1.03 to 1.18) for cognitive ability and 1.10 (1.01 to 1.19) for conscientiousness. After further adjustment for household wealth and health literacy-shown previously to be associated with participation-these associations were attenuated (ORs were 1.07 (1.00 to 1.15) and 1.07 (0.97 to 1.18), respectively)., Conclusions: We found some indication that better cognitive function and greater conscientiousness may be linked with a slightly increased likelihood of participation in bowel cancer screening. These relationships need investigation in other cohorts of older people., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Previous evaluations of area-based initiatives have not compared intervention areas with the full range of areas from top to bottom of the social spectrum to evaluate their health inequalities impact., Setting: Deprived areas subject to the New Deal for Communities (NDC) intervention, local deprivation-matched comparator areas, and areas drawn from across the socioeconomic spectrum (representing high, medium and low deprivation) in England between 2002 and 2008., Data: Secondary analysis of biannual repeat cross-sectional surveys collected for the NDC National Evaluation Team and the Health Survey for England (HSE)., Methods: Following data harmonisation, baseline and time trends in six health and social determinants of health outcomes were compared. Individual-level data were modelled using regression to adjust for age, sex, ethnic and socioeconomic differences among respondents., Results: Compared with respondents in HSE low deprivation areas, those in NDC intervention areas experienced a significantly steeper improvement in education, a trend towards a steeper improvement in self-rated health, and a significantly less steep reduction in smoking between 2002 and 2008. In HSE high deprivation areas, significantly less steep improvements in five out of six outcomes were seen compared with HSE low deprivation areas., Conclusions: Although unable to consider prior trends and previous initiatives, our findings provide cautious optimism that well-resourced and constructed area-based initiatives can reduce, or at least prevent the widening of, social inequalities for selected outcomes between the most and least deprived groups of areas., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: A large part of the socioeconomic mortality gradient can be statistically accounted for by social patterning of adult health behaviours. However, this statistical explanation does not consider the early life origins of unhealthy behaviours and increased mortality risk., Methods: Analysis is based on 2132 members of the MRC National Survey of Health and Development with mortality follow-up and complete data. Smoking behaviour was summarised by pack-years of exposure. Socioeconomic circumstances were measured in childhood (father's social class (age 4), maternal education (age 6)) and age 26 (education attainment, home ownership, head of household social class). We estimated the direct effect of early circumstances, the indirect effect through smoking and the independent direct effect of smoking on inequality in all-cause mortality from age 26 to 66., Results: Mortality risk was higher in those with lower socioeconomic position at age 26, with a sex-adjusted HR (relative index of inequality) of 1.97 (95% CI 1.18 to 3.28). Smoking and early life socioeconomic indicators together explained 74% of the socioeconomic gradient in mortality (the gradient). Early life circumstances explained 47% of the gradient, 23.5% directly and 23.0% indirectly through smoking. The explanatory power of smoking behaviour for the gradient was reduced from 50.8% to 28% when early life circumstances were added to the model., Conclusions: Early life socioeconomic circumstances contributed importantly to social inequality in adult mortality. Our life-course model focusing on smoking provides evidence that social inequalities in health will persist unless prevention strategies tackle the intergenerational transmission of disadvantage and risk.