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Background The UK Department for Work and Pensions (DWP) administers Universal Credit (UC) – the main UK benefit for people in- and out-of-work. UC is being rolled out nationally from 2013 to 2024. Citizens Advice (CA) is an independent charity that provides advice and support to people making a claim for UC. The aim of this study is to understand who is seeking advice from CA when making a UC claim and how the types of people seeking advice are changing as the rollout of UC continues. Methods Co-developed with Citizens Advice Newcastle and Citizens Advice Northumberland we performed longitudinal analysis of national data from Citizens Advice for England and Wales on the health (mental health and limiting long term conditions) and socio-demographic of 1,003,411 observations for people seeking advice with claiming UC over four financial years (2017/18 to 2020/21). We summarised population characteristics and estimated the differences between the four financial years using population-weighted t-tests. Findings were discussed with three people with lived experience of seeking advice to claim UC to help frame our interpretation and policy recommendations. Results When comparing 2017/18 to 2018/19, there was a significantly higher proportion of people with limiting long term conditions seeking advice with claiming UC than those without (+ 2.40%, 95%CI: 1.31%-3.50%). However as the rollout continued between 2018/29 and 2019/20 (-6.75%, 95%CI: -9.62%--3.88%) and between 2019/20 and 2020/21 (-2.09%, 95%CI: -2.54%--1.64%), there were significantly higher proportions of those without a limiting long term condition seeking advice than with. When comparing 2018/19 to 2019/20 and 2019/20 to 2020/21, there was a significant increase in the proportion of self-employed compared to unemployed people seeking advice with claiming UC (5.64%, 95%CI: 3.79%-7.49%) and (2.26%, 95%CI: 1.29%-3.23%) respectively. Conclusion As the rollout for UC continues, it is important to understand how changes in eligibility for UC may impact on those who need help with applying for UC. Ensuring that the advice process and application process is responsive to a range of people with different needs can help to reduce the likelihood that the process of claiming UC will exacerbate health inequalities.

ObjectivesTo assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain.Methods6658 participants aged 18–59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010–12; 15 162 participants aged 16–74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010–2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties.ResultsIn the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010–12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010–12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010–12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions.ConclusionsOur findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

IntroductionThe UK social security system is being transformed by the implementation of Universal Credit (UC), which combines six existing benefits and tax credits into a single payment for low-income households. Despite extensive reports of hardship associated with the introduction of UC, no previous studies have comprehensively evaluated its impact on mental health. Because payments are targeted at low-income households, impacts on mental health will have important consequences for health inequalities.Methods and analysisWe will conduct a mixed methods study. Work package (WP) 1 will compare health outcomes for new recipients of UC with outcomes for legacy benefit recipients in two large population surveys, using the phased rollout of UC as a natural experiment. We will also analyse the relationship between the proportion of UC claimants in small areas and a composite measure of mental health. WP2 will use data collected by Citizen’s Advice to explore the sociodemographic and health characteristics of people who seek advice when claiming UC and identify features of the claim process that prompt advice-seeking. WP3 will conduct longitudinal in-depth interviews with up to 80 UC claimants in England and Scotland to explore reasons for claiming and experiences of the claim process. Up to 30 staff supporting claimants will also be interviewed. WP4 will use a dynamic microsimulation model to simulate the long-term health impacts of different implementation scenarios. WP5 will undertake cost–consequence analysis of the potential costs and outcomes of introducing UC and cost–benefit analyses of mitigating actions.Ethics and disseminationWe obtained ethical approval for the primary data gathering from the University of Glasgow, College of Social Sciences Research Ethics Committee, application number 400200244. We will use our networks to actively disseminate findings to UC claimants, the public, practitioners and policy-makers, using a range of methods and formats.Trial registration numberThe study is registered with the Research Registry: researchregistry6697.

BackgroundPublic health policies and recommendations aim to be informed by the best available evidence. Evidence underpinning e-cigarettes policy recommendations has been necessarily limited due to the novelty of the technology and the lack of long-term epidemiological studies and trials. Some public health bodies have actively encouraged e-cigarette use whilst others have raised concerns over introducing new health risks and renormalising tobacco smoking. Using citation network analysis we investigated the author conflicts of interest and study funding statements within sources of evidence used by public health bodies when making recommendations about e-cigarette policy.MethodsWe conducted citation network analysis of public health recommendation documents across four purposively selected diverse jurisdictions: WHO, UK, Australia, and USA. We extracted all citations from 15 public health recommendation documents, with more detailed data collected for influential citations (used in 3+ recommendation documents). We analysed the relationships between the sources of evidence used across jurisdictions using block modelling to determine if similar groups of documents were used across different jurisdictions. We assessed the frequency and nature of conflicts of interest.Results1700 unique citations were included across the 15 public health recommendation documents, with zero to 923 citations per document (median = 63, IQR = 7.5–132). The evidence base underpinning public health recommendations did not systematically differ across jurisdictions. Of the 1700 citations included, the majority were journal articles (n = 1179). Across 1081 journal articles published between 1998–2018, 200 declared a conflict of interest, 288 contained no mention of conflicts of interest, and 593 declared none. Conflicts of interest were reported with tobacco (3%; n = 37 journal articles of 1081), e-cigarette (7%; n = 72), and pharmaceutical companies (12%; n = 127), with such conflicts present even in the most recent years. There were 53 influential citations, the most common study type was basic science research without human subjects (e.g. examination of aerosols and e-liquids) (n = 18) followed by systematic review (n = 10); with randomised control trial being least common (n = 4). Network analysis identified clusters of highly-cited articles with a higher prevalence of conflicts of interest.ConclusionPublic health bodies across different jurisdictions drew upon similar sources of evidence, despite articulating different policy approaches to e-cigarettes. The evidence drawn upon, including the most influential evidence, contained substantial conflicts of interest (including relationships with e-cigarette and tobacco industries). Processes to explicitly manage conflicts of interest arising from the underlying evidence base may be required when developing public health recommendations.

Teenage pregnancy is associated with numerous health risks, both to mothers and infants, and may contribute to entrenched social inequalities. In countries with high rates of teenage pregnancy there is disagreement on effective action to reduce rates. England's Teenage Pregnancy Strategy, which cost £280 million over its ten year implementation period, has been highlighted as an effective way of reducing pregnancies after rates fell by more than 50% from 1998 to 2014 and widely advocated as a replicable model for other countries. However, it is not clear whether the fall is attributable to the strategy or to background trends and other events. We aimed to evaluate the impact of the Teenage Pregnancy Strategy on pregnancy and birth rates using comparators. We compared under-18 pregnancy rates in England with Scotland and Wales using interrupted time series methods. We compared under-18 birth rates and under-20 pregnancy rates in England with European and English-speaking high-income countries using synthetic control methods. In the controlled interrupted time series analyses, trends in rates of teenage pregnancy in England closely followed those in Scotland (0.08 fewer pregnancies per 1000 women per year in England; −0.74 to 0.59) and Wales (0.14 more pregnancies per 1000 women per year in England; −0.48 to 0.76). In synthetic control analyses, under-18 birth rates were very similar in England and the synthetic control. Under-20 pregnancy rates were marginally higher in England than control. Although teenage pregnancies and births in England fell following implementation of the Teenage Pregnancy Strategy, comparisons with other countries suggest the strategy had little, if any, effect on pregnancy rates. This raises doubts about whether the strategy should be used as a model for future public health interventions in countries aiming to reduce teenage pregnancy., Highlights • England's Teenage Pregnancy Strategy has been promoted as a successful intervention. • Previous studies show a 51% drop in teenage pregnancies across the strategy period. • This study compares England with unexposed countries to test strategy effectiveness. • We found similar patterns in controls in all comparative analyses. • Our study suggests there was little or no effect of the strategy on teenage pregnancy rates.

Background The Teenage Pregnancy Strategy was published in July 1999 with the aim halving under-18 pregnancy rates in ten years. The strategy came to an end in 2010 with the UK’s change of government. Overall costs of implementation are estimated around £280m. From 1999–2014 rates of pregnancy to women aged under 18 fell by more than 50%. Hailed as a unique, nation-wide, comprehensive, evidence-based intervention, the strategy has been promoted as a reproducible model for other countries with high teenage pregnancy rates. In evaluating policy impact, observational studies alone may not be able to account for background trends and other events. We aimed to evaluate the impact of England’s Teenage Pregnancy Strategy on pregnancy and birth rates using natural experimental methods. Methods Women aged under-20 and living in England during the intervention period were the target population. UK pregnancy rates were taken from Office of National Statistics and Information Services Division Scotland reports for years 1992–2016. We compared under-18 pregnancy rates in England with Scotland and Wales as controls using interrupted time series methods. Observed level and trend changes in controls at 1999 were used to predict a ‘No Strategy’ England. We compared under-18 birth rates and under-20 pregnancy rates of England with European and English-speaking high-income countries using synthetic control methods. Estimates of births were taken from the Human Fertility Database, estimates of population from the Human Mortality Database and abortions from the European Health Information Gateway, supplemented from national statistics bodies, for years 1990–2013. Background trends were estimated using a weighted mean of control countries’ rates. Results Although pregnancies and births in England fell during the Strategy period, we found no difference compared with control. In interrupted time series analyses, trends in rates of teenage pregnancy beginning in 1999 in England were similar to Scotland (0.08 fewer pregnancies per 1,000 women per year; -0.74 to 0.60) and Wales (0.14 more pregnancies per 1,000 women per year; -0.48 to 0.76). In synthetic control analyses, yearly under-18 birth rates in England were very similar to synthetic control predictions post intervention, and under-20 pregnancy rates were marginally higher than control across the post intervention time period. Placebo testing and other sensitivity analyses supported the finding of no effect. Conclusion Our analyses cast doubt on the effectiveness of England’s teenage pregnancy strategy. These results should be factored into decision making if other countries, or England in the future, were to contemplate similar costly strategies.

Essure™ hysteroscopic sterilisation is a minimally invasive, outpatient approach to female sterilisation, which avoids the possible complications of laparoscopic sterilisation. We present our experience of the first 100 cases of the procedure performed in our unit. The successful placement rate overall was 87%. Insertion failure, more common with the older devices and in the earlier part of the series, was due to pre-existing tubal damage in the majority of cases. Our patient satisfaction survey revealed that the procedure was associated with low pain scores and high satisfaction levels.

Objective To compare flexible and rigid hysteroscopy in an outpatient hysteroscopy clinic. Design A randomized, single-blinded prospective study. Setting A one-stop, outpatient hysteroscopy clinic in a district general hospital. Subjects 96 women referred to the clinic with abnormal uterine bleeding. Main outcome measures Patient pain scores, local anaesthetic usage, need for cervical dilation, quality of view, correlation of clinical and histological findings, duration of procedure, operator's assessment of the ease of the procedure. Results Data from 83 women were analysed; three declined to enter the study, one failed to complete the pain scores and nine also had an operative hysteroscopy. Immediate median pain scores were statistically lower in the flexible hysteroscopy group, 1.2 vs. 3.6 (P = 0.001). The difference persisted 30 min after the procedure (0.4 vs. 1.1, P = 0.031). Pain experienced with endometrial biopsy was similar in the two groups (2.5 vs. 3.0, P = 0.16). There were no statistical differences between the two study arms with regard to procedure duration, quality of view, need for cervical dilation, anaesthetic usage or operator assessment of the ease of the procedure. There was agreement in clinical and histological diagnoses in all cases. The operators’ assessment of patients’ pain level correlated highly with patient pain scores. There were no statistically significant differences in any end-point between the two operators. Conclusion Flexible hysteroscopy is associated with lower levels of patient discomfort than rigid hysteroscopy. Other study variables were comparable for the two types of hysteroscopy.

Several sedimenit cores ai-ounid the coastal lake of Verlorenvlei, Westem Cape, have thus far revealed important details of the development of this semi-arid winter-rainfall environment during the late Quatemary. Complex interplay between climate change, sea-level fluctuation and human activities have characterized the Verlorenvlei record and suggests that these environments have been subject to high degrees of disturbance over time. However, due to the discontiniuous nature of the sedimentary record, the Holocene record has remained fragmentary. Investigation of a 6 in vibracore sequence at Klaarfontein (32δ25′26″S; 18δ29′40″E). an artesian spring site some 18 km inland of Eland's Bay. facilitates a more complete Holocene palaeoenivironmental reconstruction. Pollen concentrations in 37 spectra distributed through the 6 m core vary with organic content, but at all depths are stufficient to facilitate interpretation of vegetation history and reveal a high degree of dynamism in the local and regional environments. The lower sediments are characterized by elements strongly indicative of more xeric conditions and the catchment appears to have been dominated by drought-resisting woody shrubs. Local vegetation in the mid-Holocene is consistent with the occurrence of two sealevel transgressions resulting in each case in the development of a salt marsh at the site. The uppermost pollen spectra are all relatively modern (post 200 BP). Grass pollen declines from 1900 BP, possibly as a result of the occupation of the area by pastoralists, although climate change cannot be ruled out. A decline in pollen diversity towards the surface is associated with a further reduction in grass pollen and ani increase in the proportion of succulents, hence offerinig support for the hypothesis of significant colonial and post-colonial disturbance of the vegetation. The evaluation of the pollen sequence at Klaarfontein supports previous palaeoenvironmental reconstructions and at once reveals new insights regarding the complex Holocene limnology, hydrology and geomorphology of the Verlorenvlei system.

The contemporary uniqueness of the southwestern Cape environemnt suggests that its response to the environmental perturbations of the late Quaternary may have been correspondingly distinctive. Despite the wide variety of palaeoenvironmental evidence which has accumulated from within the region, a coherent picture of the evolution and development of its environments has remained elusive. Since the publication of several regional reviews over the last decade or so, a considerable body of palynological and other palaeoecological evidence has emerged which prompts a fresh synthesis as to the nature of late Quaternary environmental changes in the southwestern Cape’s fynbos biome. Although there are few sediments which date to the appropriate period, the last glacial maximum, in contrast to the situation evident in the summer rainfall region, is suggested to be a period characterised by considerably cooler and wetter conditions in certain parts of the biome. The first half of the Holocene appears to have been somewhat drier than much of the second half and the warmer temperatures of the Holocene hypsithermal are associated with reduced moisture availability. Intra-regional contrasts are evident in the response to late Quaternary environmental changes. Furthermore, it transpires that, for much of the later Quaternary and for large areas of the region, precipitation may have fluctuated out of phase with changes in the interior of the subcontinent, a situation which has great relevance to the prediction of future environmental changes and their impacts in the southwestern Cape.

A series of sediment cores extracted from what is today a large freshwater coastal lake, Verlorenvlei, has been sub-sampled, radiocarbon-dated and subjected to a range of palaeoenvironmental techniques, in particular pollen analysis, sedimentology and geochemistry. A mid-late-Holocene higher sea level is evident in the cores indicating the rapidity with which sea level change can occur and invoke other forms of environmental response. Following a hiatus in sedimentation, most probably around 3800 BP, the marine conditions at the site were replaced by fresh water as the dominant hydrological and ecological influence. Laminated organic sediments in some of the cores suggest that, around 300 years ago, a fresh water lake characterised Verlorenvlei. Since then, the picture revealed by high-resolution palynology is one of progressive levels of human disturbance both in and around the study area. Sedimentological and palaeoecological analyses of additional cores from the vlei, two from the distal (inland) and one from the proximal (coastal) end of the system, serve further to elucidate the precise nature of sea level change in the late Holocene and facilitate the construction of a refined Holocene sea level curve for the region. Environmental changes in the late Holocene are shown to be especially dynamic.

This paper presents the preliminary results of geomorphological and sedimentological investigations in the Ncamasere Valley, a seasonally back-flooded tributary of the Okavango River in northwestern Botswana. Geomorphological studies indicate the importance of the Okavango River flood regime for determining the past and present hydrology of the Ncamasere, and suggest that water levels in the Okavango have been up to 1.5 m higher at times during the Holocene compared to maximum historical flood levels. A series of cores supported by four radiocarbon dates, taken in a transect along the valley, indicate the chronology of mid- to late-Holocene sedimentation since c. 3850 yrs BP. Analyses reveal that much of the sedimentary fill within the valley is derived from Okavango back-flooding as opposed to down-valley transportation. Studies of organic horizons within cores indicate the differences in organic material generated within different ecological habitats within the Okavango system and confirm the h...

Two preliminary surveys (one during the dry season and one during the wet season) of the ostracod fauna of Verlorenvlei (Western Cape) are presented. Fifteen species were found; two are reported for the first time from Africa. Various species are indicative of slightly saline to even hypersaline conditions. The morphology and ecology of the various species are briefly discussed, in order to allow future palaeo-environmental reconstructions based on ostracod fossils from this locality.

Evidence on late Quaternary palaeoenvironments of the western and southwestern Cape of South Africa has facilitated detailed reconstructions mainly for the mountains, where organic sediment accumulation has been favoured by relatively humid climates. On the lowlands, particularly those of the west coast region, the search for sites traditionally regarded as suitable for the accumulation of sediments containing preserved fossil pollen has commenced only more recently. This area of the Western Cape Province has, however, provided Quaternary scientists with a rich archaeological record that has yet to be tested against independent lines of palaeoecological evidence. A sequence of sediments which have accumulated in what is today a large freshwater coastal lake, Verlorenvlei, has been sampled at Grootdrift, 15 km inland of the coast. A series of seven sediment cores was extracted during 1991 and three of these have now been sub-sampled, radiocarbon dated and subjected to a range of palaeoenvironmental techniques, in particular pollen analysis, sedimentology and geochemistry. Three pollen diagrams are presented which reveal the vegetation history of both the immediate Grootdrift environment and the wider catchment during several periods over the last 5500 years. A mid-Holocene higher sea-level is evident in two of the cores which were examined for pollen throughout their length. The surrounding area appears at this time to have been somewhat more arid than today. Following a hiatus in sedimentation some time after 4300 BP, the marine conditions at the site disappear and are replaced by fresh water as the dominant hydrological and ecological influence. Around the time of colonial occupation of the region, some 300 years ago, lacustrine conditions prevailed at Grootdrift and greater moisture availability is indicated in the catchment. During the last 300 years, the picture revealed by high resolution palynology of the third core is one of progressive levels of human disturbance both in and around the Verlorenvlei. Evidence from a textural and geochemical analysis of the sediments is consistent with the interpretation based on fossil pollen. The implications of this information are examined against the archaeology and palaeoecology of several cave sites in the vicinity of the vlei. The consistency apparent in the range of types of evidence suggests that some reliance can be placed on the mid-late Holocene palaeoenvironmental reconstruction at Verlorenvlei. The paper thus provides insight into the nature of the complex interactions between late Holocene climate change, sea-level fluctuation, vegetation change, vlei hydrology and human activity in the Western Cape coastal region.

The late Quaternary vegetation history of fynbos a sclerophyllous shrubland of the south‐western Cape Province of South Africa, has only recently begun to be revealed by a series of pollen diagrams...

The present distribution of lowland fynbos of the southwestern Cape coastal forelands occupies a unique yet threatened existence. Long renowned for its extraordinary species richness, the lowland fynbos now reveals a decline in diversity following the impact of recent European settlement. Fine resolution pollen analysis, conducted on a dated sediment core from the Verlorenvlei, reveals a 250 year pattern of debilitating vegetation transformations. The arrival of European colonists in the area circa 1700 is noted in the sedimentary sequence, not only with respect to changes in the pollen spectra, but also through concomitant changes in the nature and timing of sedimentation. The rapid extermination of large mammalian fauna, overgrazing by domestic stock and decades of agricultural mismanagement in a marginal landscape are considered to be the principal factors responsible for deliterious alterations of the natural disturbance regime.

Verlorenvlei, a dryland aquatic ecosystem in South Africa, has been identified as having enormous conservation importance. Although the system has Ramsar status and is widely regarded as being in ‘pristine' condition, neither statutory control nor any form of management is currently in existence. Based on the analysis of fossil pollen derived from the sediments of Verlorenvlei, a sequence of rapid changes within the riparian and aquatic vegetation is identified. Synchronous changes in the rate of sedimentation suggest a threefold increase in annual sediment deposition since the mid-18th century—the onset of colonial settlement. The pollen spectra prior to the arrival of colonial settlers suggest that abundant Poaceae (grasses) and rooted aquatic plants dominated the vegetation of the site. Radical changes in the pollen record become evident after the time of European colonization. Aquatic vegetation, including Gentianaceae (water lilies) and Potamogetonaceae, show a marked decrease while riparian vegetation, particularly reed elements such as Cyperaceae, Typhaceae and Juncaceae, are seen to increase progressively. Terrestrial pollen indicators reveal an expansion in the vegetation of classic disturbance indicators such as Asteraceae, Oxalidaceae and Scrophulariaceae. As the wetland has already endured rapid ecological adjustments in the face of colonial (and more recent) occupation of the broader landscape, it cannot be regarded as being in a ‘pristine’ state. Indeed, Verlorenvlei is interpreted as having reached a state of ‘transitional’ ecological equilibrium in which it continues to endure a number of rapid ecological changes; nonetheless, it is still worthy of conservation and management, not least because of its role as a strategic wetland in a dryland environment. Failing the timely implementation of remedial action in the form of an integrated conservation and management plan, Verlorenvlei appears destined to become irreversibly altered. Dryland aquatic ecosystems are vital aquatic resources in so called ‘Third World’ regions of the world yet, paradoxically, scientific research on, and the conservation of, these environments in the Southern Hemisphere are rare by comparison to wetland environments in the northern temperate zones. Although many dryland aquatic systems may already be altered, most are worthy of urgent management and conservation action, bearing in mind the fundamental question: ‘What is it that we wish to conserve?’. A number of recommendations for the management of dryland aquatic ecosystems such as Verlorenvlei are listed.

The current global warming controversy has sparked vigorous research activity, the ultimate aim of which is to understand the effects of predicted climatic changes on both natural and managed ecosystems. In the search for reliable and appropriate models of ecosystem response, the evidence of climate and vegetation change from the past has frequently been promoted as a valuable guide to the future. In this paper the logic of using information from the geological past is reviewed and it is concluded that the value of such evidence lies not so much in the provision of palaeoanalogues for future ecosystems, but in the insights that vegetation history can yield as to the processes accompanying climatic change. This point is made with reference to the late Quaternary vegetation history of the mountain fynbos communities in the Cederberg, SW Cape. Apparently subtle shifts in plant community features during the late Pleistocene-Holocene transition might, at first sight, support the contention that fynbos...