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Over the past decade, data-driven systems have transformed how UK public services engage with the population. This ethnographic study, conducted in one of the United Kingdom's poorest boroughs, investigates the implementation of a machine learning data system for identifying at-risk children in need of safeguarding. It examines the concept of a 'data consensus' amongst council workers pursuing the 'public good'. Within this consensus, the article explores contrasting stances on data's potential, namely that of data scientists, who use it as a tool to predict human behaviour and prevent harm, and social workers, who resist the notion that a person is predictable and therefore incapable of change. This reveals the political implications of these opaque algorithmic systems as various groups harness data in the name of public benefit. [ABSTRACT FROM AUTHOR]

Background The aim of this scoping review was to identify key research gaps and priorities in order to advance policy and practice for people living with cancer in the UK. Methods The review adhered to PRISMA guidelines for scoping review. We searched MEDLINE, EMBASE, Scopus, Web of Science and Google Scholar on 16 July 2022. There were no restrictions in terms of study design and publication time; gray literature was included. The key words, 'financial' or 'economic', were combined with each of the following words 'hardship/stress/burden/distress/strain/toxicity/catastrophe/consequence/impact.' Results 29/629 studies/reports published during 1982–2022 were eligible to be included in the review. No study conducted a comprehensive inquiry and reported all aspects of financial toxicity (FT) or used a validated measure of FT. The most three commonly reported outcomes related to financial hardship were financial well-being (24/29), benefit/welfare (17/29) and mental health status (16/29). Conclusions It is evident that FT is experienced by UK cancer patients/survivors and that the issue is under-researched. There is an urgent need for further research including rigorous studies which contribute to a comprehensive understanding about the nature and extent of FT, disparities in experience, the impacts of FT on outcomes and potential solutions to alleviate FT and related problems. [ABSTRACT FROM AUTHOR]

People with Parkinson's disease (PD) may find it difficult to identify and access the wide number of services they need and are entitled to along their complex PD journey. As part of the project OPTIM‐PARK – Optimisation of community resources and systems of support to enhance the process of living with Parkinson's Disease, document analysis was developed to create overviews of existing resources and systems of support in Denmark, Norway, Spain and the United Kingdom. Documents on community resources, policies, guidelines and professional recommendations were the main sources of information. They were sought systematically at official websites of the public sector (national and regional levels) and websites of non‐governmental organisations and scientific societies; searches were performed in October 2020 and updated in September 2021. A higher‐level cross‐national content analysis integrated all the country‐specific information. Data‐ and concept‐driven coding frames were developed; trial coding and peer review strengthened face validity and reliability. The analysis led to overviews of: (1) Key aims at patient and societal levels. (2) Key elements in form of professional approaches. (3) Community resources. (4) Legally anchored services. In general, clear descriptions of how to implement care pathways and tools to facilitate delivery were missing in the included documents, and pathways and guidelines did not include referral to general social support, social security support or labour and employment support. The results shed light on the complex support systems and resources and can inspire the planning of more comprehensive care pathways for people with PD and other long‐term conditions. [ABSTRACT FROM AUTHOR]

Notwithstanding its central place in social security policy-making and in the experiences of those on the receiving end of welfare reforms, cumulative impact is an under interrogated and theorised problem in social welfare scholarship. This paper seeks to address this in two ways. First, it draws on the lessons of the comparatively well-developed literature on cumulative impact in environmental studies to: (i) identify different dimensions of cumulative impact and (ii) best practices in undertaking cumulative impact assessments. Second, it argues that having regard to cumulative impact is not just good policy-making, but is also a legal obligation. To discharge the 'Public Sector Equality Duty' under s.149 Equality Act 2010, a public authority needs to have due regard to clear cumulative impacts between measures. In the context of social security policy-making, a failure to undertake enquiries to establish cumulative impacts between policies is likely to breach the PSED. Drawing on examples from the UK Government's Welfare Reform Act 2012 and the Welfare Reform and Work Act 2016 throughout, the paper makes the case for both the importance of addressing cumulative impact in policymaking, and the need for greater interrogation by social welfare scholarship. [ABSTRACT FROM AUTHOR]

Policy-makers frequently neglect the ways in which social policies are funded through taxation. This relationship is of critical importance because misalignment can cause social policy failure and tax injustice. This is evident with National Insurance (NI): a tax used primarily to fund the UK's state pension entitlement. This paper explains how NI is failing women and poorer people, prompting questions of why such a poorly designed, unfair and ineffective tax has persisted for so long in the UK. The paper proposes a radical solution: the payment of a universal basic pension and the abolition of NI, with consequential adjustments in income and corporation taxes to compensate for revenue losses. This paper makes a rare contribution to understanding how taxation is used to fund social welfare, and the implications of that relationship. In the UK, National Insurance (NI) is a hypothecated tax used primarily to fund state old age pensions—a contributory welfare benefit. Through historical analysis, and the exemplar of the raising of the state pension age for women, this paper demonstrates that NI fails women and poorer people more than men and the better-off: creating serious problems of social equity. A solution is proposed: the abolition of NI with consequential adjustments to income and corporation taxes, and the introduction of a universal basic pension. [ABSTRACT FROM AUTHOR]

Objectives: Public expenditure aims to achieve social objectives by improving a range of socially valuable attributes of benefit (arguments in a social welfare function). Public expenditure is typically allocated to public sector budgets, where budget holders are tasked with meeting a subset of social objectives., Methods: Decision makers require an evidence-based assessment of whether a proposed investment is likely to be worthwhile given existing levels of public expenditure. However, others also require some assessment of whether the overall level and allocation of public expenditure are appropriate. This article proposes a more general theoretical framework for economic evaluation that addresses both these questions., Results: Using a stylized example of the economic evaluation of a new intervention in a simplified UK context, we show that this more general framework can support decisions beyond the approval or rejection of single projects. It shows that broader considerations about the level and allocation of public expenditure are possible and necessary when evaluating specific investments, which requires evidence of the range of benefits offered by marginal changes in different types of public expenditure and normative choices of how the attributes of benefit gained and forgone are valued., Conclusions: The proposed framework shows how to assess the value of a proposed investment and whether and how the overall level of public expenditure and its allocation across public sector budgets might be changed. It highlights that cost-benefit analysis and cost-effectiveness analysis can be viewed as special cases of this framework, identifying the weakness with each., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section. The views expressed are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care., (Copyright © 2024 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: This paper asks whether the separation of mental health from its wider social context during the UK benefits assessment processes is a contributing factor to widely recognised systemic difficulties, including intrinsically damaging effects and relatively ineffective welfare-to-work outcomes., Methods: Drawing on multiple sources of evidence, we ask whether placing mental health-specifically a biomedical conceptualisation of mental illness or condition as a discrete agent-at the core of the benefits eligibility assessment process presents obstacles to (i) accurately understanding a claimant's lived experience of distress (ii) meaningfully establishing the specific ways it affects their capacity for work, and (iii) identifying the multifaceted range of barriers (and related support needs) that a person may have in relation to moving into employment., Results: We suggest that a more holistic assessment of work capacity, a different kind of conversation that considers not only the (fluctuating) effects of psychological distress but also the range of personal, social and economic circumstances that affect a person's capacity to gain and sustain employment, would offer a less distressing and ultimately more productive approach to understanding work capability., Conclusion: Such a shift would reduce the need to focus on a state of medicalised incapacity and open up space in encounters for more a more empowering focus on capacity, capabilities, aspirations, and what types of work are (or might be) possible, given the right kinds of contextualised and personalised support., (© 2023. The Author(s).)

Atmosphere is a neglected topic in social work, and so this article considers the production of atmospheres amongst the residents of an extant 1960s housing scheme in Edinburgh (UK). This is in order to address not only the complexity of feelings about living on such an estate but also to consider what consequences the paying of attention to atmosphere's production and effects might have for a social work concern with welfare and wellbeing. The article is based upon semi-structured and walking interviews with 17 residents – council or private renters and home-owners – of Claremont Court, a mixed, low-rise estate and analyses their description and crafting of atmosphere as a way to understand questions of belonging, welfare and community in situ. After reviewing some existing research on atmosphere and outlining methodological issues relating to the Claremont Court project, the article goes on to consider how residents described their feelings about or sense of the estate and its design before discussing the emergence of contradictory narratives about home. The production of narratives about those needing welfare support is particularly pertinent to atmospheric accounts of the housing scheme, and so the article addresses this before finally making an argument for the relevance of immersive and emplaced accounts of space and place for both social work practice and research. [ABSTRACT FROM AUTHOR]

Since the formation of the 2012 Coalition government, the UK has been subject to 12 years of neoliberal policy enacted with ferocity and vigour. This has comprised austerity measures including the retrenchment of welfare via the reshaping of the welfare state and public services according to business practices, ideals of individual responsibilisation and overwhelmingly, the notion of reducing the state's ideological and fiscal responsibility for equity and social welfare. The neoliberal state has been conceptualised by Loic Wacquant as a Centaur, boasting a liberal head, yet one atop an authoritarian body whose focus is the designated 'underclasses', the socially and economically non-compliant. The Centaur takes away with one hand while ruling punitively with the other, specifically via 'prisonfare' and 'workfare' to compel submission to precarious and sub-par employment. Although compelling, the Centaur State is justifiably critiqued for its blindness to gender and focus upon the manifestation of neoliberalism in the States. By exploring the stories of 23 women in the UK with histories of survival sex working and problematic drug use, a distinct gendered alternative reality emerges of the operation and machinations of the neoliberal state. Rather than a Centaur, marginalised women experience the Scylla State, a covert, hydra-headed beast motivated by neo-Victorian ideals of 'womanfare'. The operations of the Scylla State are unpredictable, replicate traumatising interpersonal experiences and variously involve surveillance, coercion, conditionality and the responsibilisation of victimhood to justify increasingly punitive responses to women's survival strategies in the face of increasing trauma and deprivation., (© 2023 The Authors. The British Journal of Sociology published by John Wiley & Sons Ltd on behalf of London School of Economics and Political Science.)

General practitioners ( GPs) engage with patients about a variety of social issues distinct from direct clinical work ('non-health' issues), such as health-related benefits and debt. Co-located welfare advice services could provide support to practices but have usually been considered in terms of patient rather than practice outcomes. We aimed to develop an initial programme theory for how the provision of co-located advice supports specific practice outcomes, and to identify salient barriers and enabling factors. Twenty-four semi-structured interviews with general practice staff, advice staff and service funders in two UK urban localities were conducted between January and July 2016. Data were thematically analysed and a modified Realist Evaluation approach informed the topic guide, thematic analysis and interpretation. Two outcomes are described linked to participant accounts of the impact of such non-health work on practices: reduction of GP consultations linked to non-health issues and reduced practice time spent on non-health issues. We found that individual responses and actions influencing service awareness were key facilitators to each of the practice outcomes, including proactive engagement, communication, regular reminders and feedback between advice staff, practice managers and funders. Facilitating implementation factors were: not limiting access to GP referral, and offering booked appointments and advice on a broader range of issues responsive to local need. Key barriers included pre-existing sociocultural and organisational rules and norms largely outside of the control of service implementers, which maintained perceptions of the GP as the 'go-to-location'. We conclude that co-location of welfare advice services alone is unlikely to enable positive outcomes for practices and suggest several factors amenable to intervention that could enhance the potential for co-location to meet desired objectives. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this paper is to examine the current policy of extending personal budgets to older people.Design/methodology/approach In developing this explanation, the paper draws upon a species of de-centred, post-foundationalist theory which draws attention to the way in which certain narratives can sustain a longing for the implementation of policies that are ultimately unachievable. The paper also draws upon original data from an evaluation of a national ageing charity’s project to increase take-up of personal budgets.Findings The paper draws attention to, and seeks to explain, the paradoxical discursive positioning of older adults as “the unexceptional exception” within the general narrative of universal personalisation.Research limitations/implications This analytical approach can secure a different vantage point in this debate by paying closer attention to the ideological and ethical dimensions of personalisation than has been the case until now.Practical implications The paper contributes to the critical interrogation of the personalisation agenda, in which debate (both in academic and practitioner circles) has become highly polarised.Social implications The paper contributes to discussions in critical social gerontology which point to a bifurcation of later life into, on the one hand, an ageless third age and a frailed fourth age, on the other.Originality/value The paper makes clear that the discursive positioning of older people as “the unexceptional exception” risks an inadvertent ageism. [ABSTRACT FROM AUTHOR]

We investigate the impact on social welfare of the United Kingdom (UK) policy introduced in 1980 by which public housing tenants (council housing in UK parlance) had the right to purchase their houses at heavily discounted prices. This was known as the Right to Buy (RTB) policy. Although this internationally-unique policy was the largest source of public privatization revenue in the UK and raised home ownership as a share of housing tenure by around 15%, the policy has been little analyzed by economists. We investigate the equilibrium housing policy of the public authority in terms of quality and quantity of publicly-provided housing both in the absence and presence of a RTB policy. We find that RTB can improve the aggregate welfare of low-income households only if the council housing quality is sufficiently low such that middle-wealth households have no incentive to exercise RTB. We also explore the welfare effects of various adjustments to the policy, in particular (i) to reduce discounts on RTB sales; (ii) to loosen restrictions on resale; (iii) to return the proceeds from RTB sales to local authorities to construct new public properties; and (iv) to replace RTB with rent subsidies in cash. [ABSTRACT FROM AUTHOR]

Objectives: Professionals in the United Kingdom providing care to new families affected by cleft lip and/or palate (CL/P) had to adapt to ensure families' needs were met during a time of uncertainty due to Covid-19. The aims of this study were to explore the impacts of the pandemic on CL/P care provision for new families from the perspectives of professionals working in medical and community settings along with any personal impact on professionals and their reflections on the future of CL/P care., Design: Semistructured interviews (n  =  27) were completed about experiences from March 2020 to October 2020 with consultant cleft surgeons (n  =  15), lead clinical nurse specialists (n  =  8), and staff working at the Cleft Lip and Palate Association (n  =  4). Transcripts were analyzed using inductive thematic analysis., Results: Three themes were identified: (1) the impact of Covid-19 on the provision of cleft care in the United Kingdom, including working conditions, delays to treatment, and Covid-19 policies; (2) the impact of the pandemic on professionals' mental health, including personal distress and concerns about Covid-19 exposure; and (3) reflections on the future of CL/P care, whereby professionals expressed both hope and concern about the Covid-19 recovery effort., Conclusions: The ongoing Covid-19 pandemic has impacted CL/P service delivery for new families significantly, warranting recommendations for cohesive psychological support for families in addition to a safe and resourced recovery effort. Support for professionals is also suggested, following existing evidence-based models for providers' needs that address the difficulties of working throughout challenging times.

Despite growing concerns about the welfare of horses in Great Britain (GB) there has been little surveillance of the welfare status of the horse population. Consequently we have limited knowledge of the range of welfare problems experienced by horses in GB and the situations in which poor welfare occurs. Thirty-one in-depth interviews were conducted with a cross -section of equine stakeholders, in order to explore their perceptions of the welfare problems faced by horses in GB. Welfare problems relating to health, management and riding and training were identified, including horses being under or over weight, stabling 24 hours a day and the inappropriate use of training aids. The interviewees also discussed broader contexts in which they perceived that welfare was compromised. The most commonly discussed context was where horses are kept in unsuitable environments, for example environments with poor grazing. The racing industry and travellers horses were identified as areas of the industry where horse welfare was particularly vulnerable to compromise. Lack of knowledge and financial constraints were perceived to be the root cause of poor welfare by many interviewees. The findings give insight into the range of welfare problems that may be faced by horses in GB, the contexts in which these may occur and their possible causes. Many of the problems identified by the interviewees have undergone limited scientific investigation pointing to areas where further research is likely to be necessary for welfare improvement. The large number of issues identified suggests that some form of prioritisation may be necessary to target research and resources effectively. [ABSTRACT FROM AUTHOR]

This article explores everyday interactions with the British welfare state at a moment when it is attempting to shift and transform its funding regimes. Based on a study of two London legal services providers, it draws attention to a set of actors poised between local state officers and citizens: the advisers who carry out the work of translation, helping people to actualize their rights and, at the same time, forcing disparate state agencies to work together. Advice and government services providers are increasingly part of the same system, yet advisers' work runs counter to the state's aims when formal legal process is used to challenge unfair legislation. The article reveals that ever more complex, vague, and idiosyncratic interconnections between state, business, and the third sector are emerging in the field of public services. [ABSTRACT FROM AUTHOR]

After a decade of austerity spending cuts and welfare reform, the COVID-19 pandemic has posed further challenges to the finances, health and wellbeing of working-age, low-income people. While advice services have been widely seen (and funded) as an income maximisation intervention, their health and well-being impact is less clear. Previous systematic reviews investigating the link between advice services and health outcomes have found a weak evidence base and cover the period up until 2010. This mixed methods review examined up to date evidence to help understand the health impacts of free and independent welfare rights advice services. We included evaluations of free to access advice services on social welfare issues for members of the public that included health outcomes. Through comprehensive searches of two bibliographic databases and websites of relevant organisations we identified 15 articles based on a mixture of study designs. The advice interventions evaluated were based in a range of settings and only limited information was available on the delivery and nature of advice offered. We undertook a convergent synthesis to analyse data on the effectiveness of advice services on health outcomes and to explain variation in these outcomes. Our synthesis suggested that improvements in mental health and well-being measures are commonly attributed to advice service interventions. However, there is little insight to explain these impacts or to inform the delivery of services that maximise health benefits. Co-locating services in health settings appears promising and embracing models of delivery that promote collaboration between organisations tackling the social determinants of health may help to address the inherent complexities in the delivery of advice services and client needs. We make recommendations to improve routine monitoring and reporting by advice services, and methods of evaluation that will better account for complexity and context., (© 2022 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

Purpose – This paper aims to explore the potential impact on families of a greater emphasis on safeguarding for vulnerable adults, from both a legal and a lay perspective. Design/methodology/approach – Case examples are used to illustrate some of the issues and problems that can arise in safeguarding situations. Findings – In community settings there can be a tendency for Social Services to take an antagonistic rather than a conciliatory approach when communicating with families. In the setting of a care home, an example of the appropriate use of safeguarding is outlined. Practical implications – The authors argue that Social Services should take a more conciliatory approach and be prepared to work in partnership with families. Originality/value – The discursive format and narrative approach of this paper represents a useful and informative way of presenting important and topical insights. [ABSTRACT FROM AUTHOR]

Purpose - The paper aims to explore current interest in the concept of well-being, and to trace, with examples, the growing use of design ideas in healthcare settings to reduce stress and maximise efficiency. Finally, it seeks to look at the relevance or transferability of such design principles and approaches to opportunities to enhance well-being through design in community settings. Design/methodology/approach - The potential in this approach is illustrated with some examples of design approaches applied in healthcare, teasing out the wider implications with ways to explore and arrange the patient journey, for example, or the "care pathway" for a vulnerable adult into a care or support service for maximum benefit. Findings - Thinking on enhancing well-being by design has been further advanced in applications in the health service, but a number of design concepts and approaches seem to promise similar benefits in community settings where issues in managing the health and well-being of vulnerable individuals are equally relevant. Originality/value - Design principles may be especially useful in current efforts towards creating dementia-friendly homes and communities, or "psychologically informed environments" in services for marginalized and excluded individuals. [ABSTRACT FROM AUTHOR]

Purpose - This paper aims to illustrate realities of homeless people's lives during a time of significant change in UK public sector funding and welfare policy. Design/methodology/approach - A participatory research approach was used including working with two co-researchers; two people who have direct experience of homelessness. A sustainable livelihoods approach was adapted to provide a framework for analysis. The research was undertaken during May to October 2011. Findings - The paper interrogates five areas of assets held by people themselves that support sustainable livelihoods, an existing approach used in other research. Life journey narratives show that a connected range of services, operating through an empowerment model, promote human dignity. Research limitations/implications - Findings resonate with issues identified in larger studies; however, as the funding and policy context is rapidly changing it is recommended that additional local qualitative studies could be conducted during the next three years to illustrate impacts in people's lives. Practical implications - The paper suggests front-line services must include resettlement as well as crisis and stabilising services in order to ensure homeless people can successfully move from home to home. Social implications - The research identified negative attitudes towards homeless people. By illustrating homeless people's achievements the study provides evidence of the impact of, and the value of continuing to fund, homeless services. Originality/value - The paper suggests that people who have experienced homelessness achieve a successful life with support by drawing on their considerable life experience and personal talents. This message is important for practitioners, commissioners and policy makers working through a period of change for homeless services. [ABSTRACT FROM AUTHOR]

This article draws on T H Marshall's celebrated classification of civil, political and social rights to examine the use of the courts by individuals seeking to establish rights to particular forms or models of welfare service provision. It argues that tensions between the collective and individual aspects of social rights, the relationship of social rights to inequality, and the difficulty of quantifying (and therefore enforcing) legitimate expectations, all make the use of litigation to establish social rights intensely problematic. Drawing on the recent UK Supreme Court case of R (on the Application of McDonald) v Royal Borough of Kensington and Chelsea, it goes on to suggest that it is unhelpful to think of social rights in terms of human rights: instead, we would do better to adopt Marshall's emphasis on the citizenship basis of social rights and on the social and political context within which they necessarily exist. [ABSTRACT FROM AUTHOR]

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Purpose – This paper provides a summary of evidence on a local sense of well-being gathered from the population of a mutual resident-controlled housing association, compared at various levels with national and other comparator data. It reproduces statistics and many statements from Walterton and Elgin Community Homes (WECH) residents, to shed light on questions over the potential for community-owned social landlords to promote social capital and well-being and transform communities and neighbourhoods in line with current UK government thinking on happiness, empowerment, and the Big Society agenda. Design/methodology/approach – The paper is the second part of an overview of the potential for social housing to empower people and improve well-being, from the perspective of a full community-owned social housing landlord. Professor Peter Ambrose of Brighton University led the study of the WECH population, assisted by LSE Social Policy post-graduate students who carried out the interviews of WECH residents. Dr Satsangi of the University of Stirling led the work comparing the data collected on WECH residents with other populations and datasets. The paper includes a summary of these findings, with further reflections on the implications for national housing policy. Findings – Notwithstanding the high deprivation indices for the area as a whole, residents of WECH expressed high levels of satisfaction with the neighbourhood, and greater levels of community engagement than people living in areas with comparable levels of deprivation. The findings support the hypothesis that an empowering and participatory management style – especially where based upon full community ownership and resident control – effectively enhances community engagement, activates citizenship and significantly improves individual and collective well-being. Practical implications – Happiness and well-being, it now appears, are not so much a function of incomes and costs, as a product of control and influence. Overall, and at the very least, the results should give confidence to national and local governments to drive forward their policies to mutualise social housing, where local communities wish to take over their homes. Originality/value – The 1992 WECH transfer of 921 homes from the local authority remains the only large-scale statutory (as distinct from voluntary) transfer of council housing in England and Wales to a resident-controlled community-based housing association. Therefore, WECH's experience is especially relevant for informing the Coalition Government's implementation of the statutory Right to Transfer for council tenants. [ABSTRACT FROM AUTHOR]

Purpose – The paper aims to explore the relationship between rough sleepers, welfare and policy in the city of Liverpool, taking Liverpool City Council's Homelessness Strategy 2008-2011 as a starting point. The paper takes as its premise the notion of rough sleepers as among the most vulnerable and marginalised in society, and questions how well they are protected by policy. Design/methodology/approach – The approach used is analysis and contextualisation of the strategy document in terms of welfare and criminological perspectives. Findings – The paper posits that the city's European Capital of Culture Status for 2008 has acted as a springboard for further consumerist and regeneration-driven aspirations, facilitated by restriction of entitlement to access city space for groups such as rough sleepers. The piece explores responses to rough sleepers and other "undesirable" city centre space users in Liverpool and contends that their behaviour and activities are criminalised. Ultimately, it is argued that the city, whilst it prioritises its goal of becoming a "world-class city", fails to deliver in terms of its welfare obligations. Originality/value – It is argued that the failure of the strategy to adequately consider the direct needs of rough sleepers renders them subject to other approaches, namely criminalisation. The article is valuable to both academics interested in aspects of social justice and practitioners engaged in policy making, in that it highlights some of the ways in which policy can fail to meet its basic requirements. [ABSTRACT FROM AUTHOR]

This paper examines the subtle ways in which welfare professionals in the UK construct Gypsy culture as subordinate to the dominant Western concept of 'civilization'. Qualitative empirical evidence is presented to show how notions of a resistance to processes of individualization and social integration-which draw on conflicting interpretations of childhood and a perceived lack of aspiration among Gypsy-Travellers-are seen as legitimate grounds for state and social welfare intervention. The paper argues that a strong group orientation and a more marked gendered division of labour are constructed as being at odds with these dominant social processes. It is posited that the 'civilizing' project against Gypsy-Travellers ignores cultural norms and values resulting in the perception that they are undeserving. The paper suggests that theoretical accounts of social processes at a society wide level require revision in order to understand their varying impact on peripheral minorities in specific spaces. [ABSTRACT FROM AUTHOR]

Background This study investigates social inequalities in self-rated health dynamics for working-aged adults in four nations, representing distinct welfare regime types. The aims are to describe average national trajectories of self-rated health over a 7-year period, identify social determinants of cross-sectional and longitudinal health and compare cross-national patterns. Methods Data are from national household panel surveys in Britain, Germany, Denmark and the USA. The self-rated health of working-age respondents is measured for the years 1995–2001. Social indicators include education, occupational class, employment status, income, age, gender, minority status and marital status. Latent growth curve models are used to estimate both individual change and average national trajectories of self-rated health, conditioned on the social indicators. Results Ageing-vector graphs reveal general declines in health as people age. They also show differential patterns of change for specific national cohorts. Older cohorts in Denmark had poorer health and young cohorts in the USA had better health in 2001 than 1995. Social covariates predicted baseline health in all four countries, in ways that were consistent with welfare regime theories. Once inequalities in baseline health were accounted for, the few determinants of mean health decline occurred mainly in the USA, again in line with theoretical expectations. Finally, trajectories of health for those in average and advantaged social circumstances were similar, but disadvantaged individuals had much poorer health trajectories than ‘average’ individuals. The differences were greatest in the countries with lower levels of public transfers. Conclusion National differences in self-rated health trajectories and their social correlates may be attributed partly to welfare policies. [ABSTRACT FROM PUBLISHER]

From a child-focused lens, effective social protection requires an understanding of the sources of vulnerability faced by children, and appropriate responses. One of the useful aspects of the increased prominence of cash transfers in the social protection debate has been to highlight the fact that for many children living in developing countries, economic poverty is a major driver of children's vulnerability and deprivation. However, without taking away from the crucial role of cash transfers, it is also clear that cash alone may not always be the optimum response to children and families' vulnerability. Social welfare services have an important role to play within social protection, but within developing countries this greater role faces two key challenges: weak social welfare services provision and the challenges of incorporating this into the already demanding social protection policy agenda. These challenges point to a number of questions requiring further research and learning. [ABSTRACT FROM AUTHOR]

Since the move to quasi-federalism in the 1990s, different territorial welfare mixes on adult social care (ASC) have emerged in the four nations of the UK. This study explores policy actors' views on their effectiveness in the pandemic with reference to the role of institutions, trust and transparency. The analysis is based on extensive secondary data analysis and primary interviews with key individuals involved in the delivery and regulation of ASC. The findings highlight how the pandemic exposed existing pathologies and the need for reform in all four systems. Notably, the analysis shows how the present market-based tendering systems for allocating ASC contracts undermine inter-personal and institutional trust and compromise care quality. The wider significance of this lies in showing the pivotal role of trust during the emergency and that post-pandemic welfare reform needs to embed trust-building measures to deliver effective care. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to study the similarities of the normative ideas underpinning the welfare-to-work measures for young people in Hong Kong and the UK. These normative ideas include the two respective Governments' views on their ideal model of the relationship between individual and society, and Etzioni's and Confucian ideas on how people's attempts to fulfill social obligations can reduce moral deficits. It is believed that the study of these issues contributes to the examination of the ethnocentric bias in the analysis of social welfare and different ways that non- Western governments organize social welfare in response to foreign ideas. Design/methodology/approach - The paper starts by discussing the ethnocentric bias in the study of social welfare. Then it examines the similarities of the normative ideas of the welfare-to- work measures for young people in Hong Kong and the UK, and discusses how the examination of these similarities helps us understand the ethnocentric bias in the analysis of social welfare. Findings - The paper shows the ethnocentric bias arising from over-emphasizing the differences between the ways in which social welfare is organized in Western societies and non-Western societies, and the ethnocentric bias arising from taking for granted that people in non-Western societies passively accept the dominance of Western models in shaping the development of their social welfare system, even if it appears that Western ideas share many similarities to their indigenous ideas. Originality/value - The paper shows different types of ethnocentric bias in the analysis of social welfare and different possible ways that non-Western governments could organize social welfare in response to foreign ideas. [ABSTRACT FROM AUTHOR]

Background: Terminal illness presents a financial challenge to many households, but in Britain the situation should be eased by state benefits, such as attendance allowance, which is available to everyone in the last six months of life without means testing. Aim: To investigate the use of health and social services, payments and benefit receipt by individuals in differing financial circumstances in the year before death. Methods: Analysis of individual level panel data for 1652 community-dwelling decedents from 12 waves of the British Household Panel Study (1991-2003). Results: In the year before death, over 90% of decedents saw their GP, and around one-third spent some time in hospital. More than 80% paid no fees for any services. Over a third of decedents aged over 65 reported financial strain, but only 13.9% of these were receiving attendance allowance. People who felt that they were having financial difficulties were more likely to be frequent attenders in primary care, taking age, health status and other factors into account (adjusted OR = 1.9, 95% CI = 1.3-2.6, P < 0.001). Older age was associated with less use of primary, but not secondary care. Conclusions: Financial strain was common, but benefit uptake low. Primary health care professionals saw nearly all decedents in their last year, and could play an important role in ensuring that the elderly and the less well off are aware of the services and benefits available to them. [ABSTRACT FROM AUTHOR]

Growing demands on welfare services, arising from expanding populations of older people in many countries, has led policy makers to consider the use of information and communications technologies (ICTs) as a means to transform the cost-effective delivery of health and social care. The evidence for these claims is examined by reporting the main findings of a review of worldwide published literature documenting the adoption of health informatics applications to improve health and social care for older people. It focuses around two dimensions of the UK government's programme for ‘modernising’ public services, which emphasise the use of ICTs to facilitate the sharing of health and social services information and its potential to foster person-centred approaches to independent living. Findings suggest that there is little evidence that these dimensions have been realised in practice and the perceived incompatibility between them is more likely to produce expensive and ineffective health informatics outcomes. [ABSTRACT FROM AUTHOR]

Purpose - The purpose of this paper is to present a conceptual and empirical analysis of the rationale and enactment of consumer discourses in reformed British welfare administration, through a focus on consumption and the service interaction. The paper aims to explore how administrators use these discourses to manage consumption in particular ways in order to promote individual enterprise and employability, and analyse the pivotal role of front-line workers in these efforts. Design/methodology/approach - The paper draws from range of data sources collected in a case study of Jobcentre Plus, including analysis of public and internal documents, observation of six public offices and interviews with 13 front-line staff. Findings - Images of customer sovereignty are used alongside heightened control to try to shape claimants' motivation and capacity for work. Front-line staff, mainly endorse reformed structures, but their view of claimants is complex, departing from the images fostered by administrators. Research limitations/implications - The paper highlights the importance of context-specific understanding of deployment of consumer discourses in public sector, but interview data are exploratory and further research is needed. Practical implications - The paper highlights complexities inherent in customer orientation in welfare administration and the pivotal role of front-line in reforms. Originality/value - The paper provides a distinctive approach to analysis of customer concept in public sector reform, through focus on consumption and the service interaction. [ABSTRACT FROM AUTHOR]

Existing approaches to the economic regulation of airports are currently under (or just completed) review in the UK and New Zealand. One of the most critical issues facing policy-makers is whether it is preferable to adopt a single-till or dual-till approach. This paper aims to analyse the potential loss of social welfare as a result of adopting a single/dual-till approach in three airport pricing scenarios. The results show that the dual-till approach is desirable when aeronautical capacity is fully utilised or already over-utilised, while the single-till approach is preferable where excess capacity exists. [Copyright &y& Elsevier]

This article compares UK and US social welfare, policy and practice responses to homelessness, with the aim of identifying differences and similarities in the systems, and drawing out lessons for future policy and practice interventions, particularly as they relate to researching the issues. An introductory section briefly sets out the policy and practice context for homelessness in both countries. Next, the main part of the article systematically highlights the continuities between the response to homelessness in the UK and US, and seeks to explain some of the questions arising from this. Finally, the article draws this together by discussing implications for future interventions and research. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Abstract Stroke affects 120 000 people each year in the UK and is the most common cause of adult-onset disability. Most stroke patients are cared for at home by informal carers. Support for these carers is provided by the community services, but although single-item measures have shown that there is a relatively high level of dissatisfaction with those services, there is no specific satisfaction measurement instrument. The present study aimed to construct and initially validate a questionnaire to measure carers’ satisfaction with community services for clinical and research purposes. Qualitative interviews with a purposive sample of informal carers of stroke patients identified via stroke unit discharge records gave information about content, context and language. Together with information from the carers’ literature, this formed the basis of the questionnaire. A self-completion questionnaire proved unacceptable to carers with a very poor response rate (20%). Face-to-face interviews were more acceptable, with the questionnaire taking approximately 10 minutes to administer. All carers approached agreed to take part and only three carers dropped out from follow up, all because of reasons not related to the study. Initial validity and reliability testing with a sample of 44 carers identified through stroke groups and general practice showed good correlation with a single-item satisfaction measure (RHO = 0.797), test–retest reliability (RHO = 0.885) and inter-rater reliability (RHO = 0.868), and a high degree of internal consistency (Cronbach's alpha = 0.859). Further validation with larger and more diverse groups of informal carers is needed before the questionnaire can be considered to be a robust and reliable tool. Factor analysis revealed seven factors: information about community support and involving the carer; amount, appropriateness and coordination of services; information about stroke; speed of change and concern about the carer;... [ABSTRACT FROM AUTHOR]

Two of the fundamental purposes for establishing the National Health Service (NHS) were to increase social welfare and improve social justice. Decisions to increase NHS investment should ideally be taken with these fundamental objectives in mind. Given that society faces resource constraints, increased financial investment in the NHS will always involve forgone investment elsewhere, and it may never be possible to determine with any degree of certainty whether further real investment in the NHS will increase overall social welfare. If the Government decides to increase NHS investment for political reasons, it should therefore at least try to ensure that the methods by which it raises extra revenue improve social justice. The introduction of an NHS premium payment for high earners would be a progressive measure consistent with this objective. [ABSTRACT FROM PUBLISHER]

This article explores the prognosis for social welfare law provision in the light of the government's plans for the Community Legal Service. It considers whether the involvement of both the advice sector and the traditional legal profession can provide the basis for stable and comprehensive provision of social welfare law. I conducted in-depth interviews with CAB workers and local solicitors in the large conurbation served by two CABx who participated in the non-solicitor franchise pilot in 1997. The research focused on the relationships between the legal service providers and the impact of the franchise operation on the CAB. Although harmonious relationships were found to be largely intact at a local level, the franchise raised considerable tension within the CABx that must serve as a cautionary note to any optimism about 'establishing the Community Legal Service'. [ABSTRACT FROM AUTHOR]

Drawing on multisited qualitative research in Italy and the UK, this paper documents the dark side of onward migration and the experiences faced by Italian-Bangladeshis in the UK after the Brexit referendum. The findings show that compared to their position in Italy, Italian-Bangladeshis experienced a downgrading in symbolic, identity-related, and, specifically, socio-economic and cultural aspects in the UK society. The paper also uncovers the potential strategies that Italian-Bangladeshis intend to adopt in case they lose the special rights provided to them by EU citizenship after Brexit. Since the majority of them have moved to the United Kingdom to build a future for their children, they find themselves forced to further reconfigure their strategies and reactivate different degrees of mobility in order to avoid the loss of social rights (access to welfare, the status of citizens) and material resources (housing and better working conditions) that they have long assumed., (© 2021 London School of Economics and Political Science.)

Trends in real national income are typically assessed using aggregate indicators such as GDP per capita, or mean household income, whereas the income distribution literature focuses on trends in income inequality. By contrast this paper takes an integrated approach to real national income measurement; it uses methods incorporating both size and distributional considerations, and applies them to household income microdata in order to measure changes in real income in the U.K. during the 1980s. A parametric class of decomposable real income indices is proposed which complements quasi-ordering methods such as rank and generalised dominance criteria by telling us how much real income increased over the period (if at all). The indices are also additively decomposable by population subgroup, a property which helps reveal who the gainers and losers were. The analysis also draws attention to the normative and statistical issues raised by the presence of a few very small incomes. [ABSTRACT FROM AUTHOR]

In the UK few if any regular processes explicitly address comparisons of value for money between spending in different government departments, despite the existence of mechanisms that could in principle achieve that. This leaves a very important gap in evidence and means that decisions about public spending allocations are likely to miss opportunities to improve social welfare from existing budgets. Greater attention to the development of methods and evidence to better inform the allocation of public sector spending between departments is therefore urgently needed. We identify a number of possible approaches to this-some of which are being used in different countries-and highlight their strengths and weaknesses. We propose a new, pragmatic approach that incorporates a generic descriptive system to measure the disparate outcomes produced by public sector activities in a commensurate manner. Discrete-choice experiments could be used to generate evidence of the relative importance placed on different aspects of public sector outcomes by members of the general public. The proposed approach would produce evidence on value for money across departments, and the generation of evidence on public preferences to support that., (© 2021. The Author(s).)

Background: Population-based data are presented on the nature of dying in intellectual disability services., Methods: A retrospective survey was conducted over 18 months with a sample of UK-based intellectual disability service providers that supported over 12,000. Core data were obtained for 222 deaths within this population. For 158 (71%) deaths, respondents returned a supplemented and modified version of VOICES-SF., Results: The observed death was 12.2 deaths per 1,000 people supported per year, but just over a third deaths had been deaths anticipated by care staff. Mortality patterns, place of usual care and availability of external support exerted considerable influence over outcomes at the end of life., Conclusion: Death is not a common event in intellectual disability services. A major disadvantage experienced by people with intellectual disabilities was that their deaths were relatively unanticipated. People with intellectual disabilities living in supported living settings, even when their dying was anticipated, experienced poorer outcomes., (© 2020 The Authors. Journal of Applied Research in Intellectual Disabilities published by John Wiley & Sons Ltd.)

Background: Social prescribing initiatives are widely implemented in the UK National Health Service to integrate health and social care. Social prescribing is a service in primary care that links patients with non-medical needs to sources of support provided by the community and voluntary sector to help improve their health and wellbeing. Such programmes usually include navigators, who work with referred patients and issue onward referrals to sources of non-medical support. This systematic review aimed to assess the evidence of service user outcomes of social prescribing programmes based on primary care and involving navigators., Methods: We searched 11 databases, the grey literature, and the reference lists of relevant studies to identify the available evidence on the impact of social prescribing on service users. Searches were limited to literature written in English. No date restrictions were applied, and searches were conducted to June 2018. Findings were synthesized narratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate the methodological quality of included studies., Results: Sixteen studies met the inclusion criteria. The evidence base is mixed, some studies found improvements in health and wellbeing, health-related behaviours, self-concepts, feelings, social contacts and day-to-day functioning post-social prescribing, whereas others have not. The review also shows that the evaluation methodologies utilized were variable in quality., Conclusion: In order to assess the success of social prescribing services, more high quality and comparable evaluations need to be conducted in the future.International Prospective Register of Systematic Reviews number: CRD42017079664., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

There is increasing emphasis on psychological and social approaches to managing and treating mental illness, including a growing evidence base on the effectiveness of community-based social interventions including arts and heritage activities, library programmes, volunteering schemes, nature-based activities and community groups. However, there is a gap in understanding of what the barriers to, and enablers of, working with individuals with mental illness might be for the community and voluntary sector. A qualitative approach was used involving focus groups with non-profit organisations delivering social activities within communities across the United Kingdom. Behaviour Change Theory, the COM-B model and the Theoretical Domains Framework, were employed as the theoretical framework, to develop interventions to address the barriers raised. Representatives of the organisations reported being motivated by the mental health needs of others, and by seeing the benefits of participation. Further motivations included expanding inclusion, and economic motivation to ensure sustainability. Strengths identified included offering innovative, responsive services that were distinct from conventional mental health services. Running these services demanded new and potentially challenging skills, such as understanding statutory responsibilities, and being able to train and support staff. Further challenges included maintaining boundaries between their roles as community organisations and clients' mental health needs and avoiding burn-out. Ability to deliver this work was enhanced by support of peer organisations and opportunities to share practice. However, funding was often short term, and complex to obtain, which could destabilise organisations' sustainability. Lack of transparency around the process, differences in language between the community and health sectors, and confusion around commissioning pathways undermined the potential opportunity offered by social prescribing policy. Interventions to address these barriers were identified, including long term funding to support core costs, training on engaging with the commissioning process, around mental health support and safeguarding, and developing mentoring schemes and local co-operatives of organisations for developing partnerships with the health sector., Competing Interests: The authors have declared that no competing interests exist.

This paper presents the lived experiences of individuals with mental illness as they navigate the benefits landscape in an age of welfare reform in the UK. We focus on the impacts upon their well-being and daily geographies. We articulate the relationship between welfare reform and mental health using the concept of poverty management and its 'missing geographies', in which everyday well-being and routines are dismissed by the restructuring welfare system. We liken this dismissal to a shift towards a narrower and more unforgiving mode of poverty management, where even the smallest misstep can unravel the entire edifice of everyday survival and well-being., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Social prescribing (SP) allows health professionals to refer primary care patients toward health and wellbeing interventions and activities in the local community. Now widely implemented across the UK and adopted in other nations, questions arise concerning the modelling of present and future schemes, including challenges to full engagement encountered by stakeholders, which lie beyond the scope of traditional evaluations. Critical Systems Thinking (CST) allows for holistic analysis of fields where multiple stakeholders hold diverse interests and unequal power., Methods: We use CST to (a) critically examine a developing rural social prescribing scheme from multiple stakeholder perspectives and (b) present a relational model for local social prescribing schemes. Our fieldwork included 24 in-depth interviews, regular planning meetings with key stakeholders, and discussions with those involved with national and international SP landscaping. A modified grounded theory approach was used for the analysis, and to consider the core elements of social prescribing sustainability., Results: Our study confirms that local social prescribing schemes must operate with numerous stakeholder interests in mind, seeking to address real life social complexity and offer integrated solutions to multifaceted issues. Three main areas are discussed: holistic vision and boundary judgments; barriers and facilitators; relational issues and "emotional buy in". Problems for staff include selecting suitable clients, feedback and technological issues and funding and evaluation pressures. Barriers for clients include health, transport and expense issues, also lack of prior information and GP involvement. Emotional "buy-in" emerged as essential for all stakeholders, but hard to sustain. Based on our findings we propose a positive relational model comprising shared vision, confidence and commitment; motivation and encouragement, support and wellbeing focus, collaborative relationships, communication and feedback, access to information /resources, learning in and from action, with emotional "buy-in" at its heart., Conclusion: Those implementing social prescribing in different localities inevitably face hard choices about what and whom to include. Research on the sustainability of social prescribing remains limited, studies are required to ascertain which "holistic" models of social prescribing work best for which communities, who are the main beneficiaries of these approaches and how "buy-in" is best sustained.

Shrinking state spending in the UK has been accompanied by a profound restructuring of the welfare system, leading to financial insecurity for many people, culminating in extreme stress and serious deterioration of physical and mental health. Theory surrounding the impact of welfare advice on stress is lacking; this paper undertakes an in depth exploration of the experiences of stress among welfare advice seekers, considering these in light of existing substantive theories of stress and coping to generate new insight. A thematic analysis explored the experiences of stress in welfare advice seekers. Four overarching themes and twelve subthemes emerged. They are further understood utilising traditional theories of stress (Transactional Model of Stress and Coping and the Conservation of Resources theory), which then underpin the development of a 'Stress Support Matrix' and a holistic theory related specifically to welfare, stress and coping., Competing Interests: The authors have declared that no competing interests exist.

Background: Universal Credit, a welfare benefit reform in the UK, began to replace six existing benefit schemes in April, 2013, starting with the income-based Job Seekers Allowance. We aimed to determine the effects on mental health of the introduction of Universal Credit., Methods: In this longitudinal controlled study, we linked 197 111 observations from 52 187 individuals of working age (16-64 years) in England, Wales, and Scotland who participated in the Understanding Society UK Longitudinal Household Panel Study between 2009 and 2018 with administrative data on the month when Universal Credit was introduced into the area in which each respondent lived. We included participants who had data on employment status, local authority area of residence, psychological distress, and confounding variables. We excluded individuals from Northern Ireland and people out of work with a disability. We used difference-in-differences analysis of this nationally representative, longitudinal, household survey and separated respondents into two groups: unemployed people who were eligible for Universal Credit (intervention group) and people who were not unemployed and therefore would not have generally been eligible for Universal Credit (comparison group). Using the phased roll-out of Universal Credit, we compared the change in psychological distress (self-reported via General Health Questionnaire-12) between the intervention group and the comparison group over time as the reform was introduced in the area in which each respondent lived. We defined clinically significant psychological distress as a score of greater than 3 on the General Health Questionnaire-12. We tested whether there were differential effects across subgroups (age, sex, and education)., Findings: The prevalence of psychological distress increased in the intervention group by 6·57 percentage points (95% CI 1·69-11·42) after the introduction of Universal Credit relative to the comparison group, after accounting for potential confounders. We estimate that between April 29, 2013, and Dec 31, 2018, an additional 63 674 (95% CI 10 042-117 307) unemployed people will have experienced levels of psychological distress that are clinically significant due to the introduction of Universal Credit; 21 760 of these individuals might reach the diagnostic threshold for depression., Interpretation: Our findings suggest that the introduction of Universal Credit led to an increase in psychological distress, a measure of mental health difficulties, among those affected by the policy. Future changes to government welfare systems should be evaluated not only on a fiscal basis but on their potential to affect health and wellbeing., Funding: Wellcome Trust, UK National Institute for Health Research, and Medical Research Council., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

The importance of Social Prescribing (SP) has been highlighted in the National Health Service (NHS) Long-Term Plan. SP is enabling healthcare professionals to refer patients to a link worker, to co-design a non-clinical social prescription to improve their health and well-being. Our aim was to explore perceptions, understanding, and awareness of SP amongst United Kingdom (UK) medical students.Views were collected using pre- and post-session surveys around teaching sessions in 27 UK medical schools as part of NHS England's National SP Student Champion Scheme. Pre-session surveys suggested 93% (n = 848) of respondents had not heard of the concept of SP before the session. Post-session surveys highlighted that 98% (n = 895) regarded the concept as useful and relevant to their future careers.Findings show a lack of awareness regarding Social Prescribing (SP) amongst UK medical students. New strategies are needed to ensure the doctors of tomorrow are equipped with the necessary tools to achieve the recent outcomes for graduates and implement plans for the NHS and general practice which highlight the importance of personalised care. We believe general practice can play an integral role in shaping values and beliefs amongst tomorrow's doctors through formal education and mentoring.

Aim: To evaluate the impact of 'holistic' link-workers on service users' well-being, activation and frailty, and their use of health and social care services and the associated costs., Background: UK policy is encouraging social prescribing (SP) as a means to improve well-being, self-care and reduce demand on the NHS and social services. However, the evidence to support this policy is generally weak and poorly conceptualised, particularly in relation to frail, older people and patient activation. Torbay and South Devon NHS Foundation Trust, an integrated care organisation, commissioned a Well-being Co-ordinator service to support older adults (≥50 years) with complex health needs (≥2 long-term conditions), as part of its service redesign., Methods: A before-and-after study measuring health and social well-being, activation and frailty at 12 weeks and primary, community and secondary care service use and cost at 12 months prior and after intervention., Findings: Most of the 86 participants achieved their goals (85%). On average health and well-being, patient activation and frailty showed a statistically significant improvement in mean score. Mean activity increased for all services (some changes were statistically significant). Forty-four per cent of participants saw a decrease in service use or no change. Thirteen high-cost users (>£5000 change in costs) accounted for 59% of the overall cost increase. This was largely due to significant, rapid escalation in morbidity and frailty. Co-ordinators played a valuable key-worker role, improving the continuity of care, reducing isolation and supporting carers. No entry-level participant characteristic was associated with change in well-being or service use. Larger, better conceptualised, controlled studies are needed to strengthen claims of causality and develop national policy in this area.