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BackgroundWhile in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally.MethodsWe conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country.ResultsPossible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight.ConclusionsThe review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

Background Most research on community empowerment provides evidence on engaging communities for health promotion purposes rather than attempts to create empowering conditions. This study addresses this gap. Intervention Big Local started in 2010 with £271M from the National Lottery. Ending in 2026, it gives 150 relatively disadvantaged1 communities in England control over £1M to improve their neighbourhoods. Objective To investigate health and social outcomes, at the population level and among engaged residents, of the community engagement approach adopted in a place-based empowerment initiative. Study design, data sources and outcome variables This study reports on the third wave of a longitudinal mixed-methods evaluation. Work package 1 used a difference-in-differences design to investigate the impact of Big Local on population outcomes in all 150 Big Local areas compared to matched comparator areas using secondary data. The primary outcome was anxiety; secondary outcomes included a population mental health measure and crime in the neighbourhood. Work package 2 assessed active engagement in Big Local using cross-sectional data and nested cohort data from a biannual survey of Big Local partnership members. The primary outcome was mental well-being and the secondary outcome was self-rated health. Work package 3 conducted qualitative research in 14 Big Local neighbourhoods and nationally to understand pathways to impact. Work package 4 undertook a cost-benefit analysis using the life satisfaction approach to value the benefits of Big Local, which used the work package 1 estimate of Big Local impact on life satisfaction. Results At a population level, the impacts on ‘reporting high anxiety’ (–0.8 percentage points, 95% confidence interval –2.4 to 0.7) and secondary outcomes were not statistically significant, except burglary (–0.054 change in z-score, 95% confidence interval –0.100 to –0.009). There was some effect on reduced anxiety after 2017. Areas progressing fastest had a statistically significant reduction in population mental health measure (–0.053 change in z-score, 95% confidence interval –0.103 to –0.002). Mixed results were found among engaged residents, including a significant increase in mental well-being in Big Local residents in the nested cohort in 2018, but not by 2020; this is likely to be COVID-19. More highly educated residents, and males, were more likely to report a significant improvement in mental well-being. Qualitative accounts of positive impacts on mental well-being are often related to improved social connectivity and physical/material environments. Qualitative data revealed increasing capabilities for residents’ collective control. Some negative impacts were reported, with local factors sometimes undermining residents’ ability to exercise collective control. Finally, on the most conservative estimate, the cost–benefit calculations generate a net benefit estimate of £64M. Main limitations COVID-19 impacted fieldwork and interpretation of survey data. There was a short 4-year follow-up (2016/20), no comparators in work package 2 and a lack of power to look at variations across areas. Conclusions Our findings suggest the need for investment to support community organisations to emerge from and work with communities. Residents should lead the prioritisation of issues and design of solutions but not necessarily lead action; rather, agencies should work as equal partners with communities to deliver change. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information. Plain language summary The Communities in Control study is looking at the health impacts of the Big Local community empowerment programme, funded by the National Lottery Community Fund and managed by Local Trust (a national charitable organisation). Residents of 150 English areas have at least £1M and other support to improve the neighbourhoods. There have been three phases of the research. This report shares findings from their third phase, which began in 2018. First, we used data from a national survey and data from national health and welfare services to compare changes in mental health between people living in Big Local areas and those in similar areas that did not have a Big Local partnership. Furthermore, we also used publicly available data on crime in the neighbourhoods. We found weak evidence that Big Local was linked with improved mental health and a reduction in burglaries. Second, we used data from a survey conducted by Local Trust to look at health and social impacts on the most active residents. We found an increase in mental well-being in 2018 but this was not maintained in 2020, probably due to the COVID-19 pandemic. Third, we did interviews and observations in 14 Big Local areas to understand what helps and what does not help residents to improve their neighbourhoods. We found that partnerships need to have legitimacy, the right balance of support, and learning opportunities. Residents suggested that creating social connections and welcoming social spaces, improving how people view the area and tackling poverty contributed to health improvements. Direct involvement in Big Local was both stressful and rewarding. Finally, we did a cost–benefit analysis by putting a monetary value on residents’ increase in life satisfaction due to Big Local and comparing it with the costs of Big Local. We found that the benefits exceed the costs by at least £60M, suggesting that Big Local provides good value for money. Scientific summary Background This research was commissioned in response to a call in 2016 by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (PHRP) for research ‘to address urgent gaps in the evidence on which interventions, using a community engagement approach, are effective in improving health and well-being and reducing health inequalities.’ We identified that the most glaring gaps were in relation to community empowerment initiatives. In theory these have great potential for reducing health inequalities, but research has focused instead on initiatives adopting a much narrower model of engagement of communities in professional-led interventions. We were able to take advantage of the Big Local (BL) programme across England, a rare example of a nationwide experiment in community empowerment. Big Local is the largest community empowerment initiative implemented in England. Launched in 2010 with £271M from the National Lottery Community Fund, and ending in 2026, it involves giving 150 relatively disadvantaged communities in England control over £1M each to enable residents to improve their neighbourhoods. It is overseen by a national organisation, Local Trust, and managed by a BL partnership board in each area, with at least 51% resident members. Our Communities in Control (CiC) study is a long-term evaluation spanning 7 years, with the latest 3 years funded by PHRP. It offers an unparalleled opportunity to learn from the BL experience for future community empowerment initiatives, focusing on the effects on health and well-being and on reducing health inequalities. Research objectives Building on two earlier phases in 2014–15 and 2015–17, the objectives of this third phase of the CiC study were to: investigate longer-term population-level health and social outcomes of BL investigate impacts of BL on health and well-being of engaged residents assess changes in collective control over decisions and actions among BL residents and pathways to changes identified illuminate residents’ perspectives on health and well-being impacts and pathways to these conduct an economic evaluation of BL draw out implications for the future design and evaluation of place-based initiatives that aim to increase collective control, particularly in disadvantaged communities. Methods The study adopted a systems theoretical framework. It is a longitudinal mixed-methods evaluation comprising four work packages. Work package (WP) 1 focused on Objective 1. Secondary data were analysed to assess whether BL had any positive impacts on social and health outcomes for populations in BL neighbourhoods. It employed difference-in-differences (DiD) methods comparing changes in outcomes in BL areas to those in comparator areas between 2011–15 and 2016–19. Comparator areas were matched to BL areas based on observed characteristics such as the Index of Multiple Deprivation, population ethnic and age profiles from the 2011 census and the Office for National Statistics (ONS) area classification. The primary outcome, from the Annual Population Survey, was a binary variable taking the value 1 if individuals reported a score of more than 6 in response to the question ‘Overall, how anxious did you feel yesterday?’, where 0 is ‘not at all anxious’ and 10 is ‘completely anxious’. Secondary outcomes included a composite measure of population mental health, recorded crimes and antisocial behaviour. Work package 2 addressed Objective 2, assessing whether BL had any positive health impacts for actively engaged residents using the 2016, 2018 and 2020 waves of a biannual survey of BL partnership members conducted by Local Trust. The analysis used both the repeated cross-sectional sample provided by the survey and a nested cohort of partnership members who completed all three surveys. The primary outcome was the Short Warwick–Edinburgh Mental Well-being Scale and the secondary outcome self-rated general health status. Unfortunately, we were unable to construct comparators as planned using the 2016, 2018 and 2020 Health Survey for England, because the relevant questions were not in the 2018 survey and the survey was not undertaken in 2020. Work package 3 addressed Objectives 3 and 4. First, qualitative in-depth interviews with national BL stakeholders and informants with expertise in place-based policies aimed to identify changes in the BL programme over time and explore the relationship with national policy. Second, continuing our longitudinal qualitative research, we conducted 171 interviews in 14 areas with people actively involved with BL from November 2018 to January 2021 (overlapping with the pandemic). Interviews covered perceptions of processes enabling or constraining residents’ attempts to improve their area and the impact of BL on health and well-being. In the analysis, we drew on the data from earlier phases of the CiC study. We also conducted observations of BL partnership meetings. Work package 4 addressed Objective 5 by conducting a cost–benefit analysis using the life satisfaction approach to value the benefits of Big Local. This approach compares the impact of an intervention on life satisfaction to the impact of an increase in income on life satisfaction. It used the DiD estimate of the impact of BL on life satisfaction from WP1, estimates of annual household income in BL areas from the ONS, and average household sizes in the BL areas from the 2011 census to put a monetary value on the benefits generated by BL. It then compared the benefits to the costs, that is, the funding BL areas received and the value of the unpaid hours provided by BL partnership members (estimated from responses to the biannual survey of BL partnership members). Results For Objective 1, we found limited evidence for population-level social or health impacts in BL areas versus comparators. The estimated impact on the primary outcome – reporting high anxiety yesterday – was small and not statistically significant (–0.8 percentage points, 95% CI –2.4 to 0.7). Similarly, the estimated impacts on the secondary outcomes were small and not statistically significant, with the exception of burglary (–0.054 change in z-score, 95% CI –0.100 to –0.009). However, there is evidence that BL had some effect on reducing levels of anxiety after 2017. Furthermore, in BL areas that had spent more than 80% of their grant by 2019/20 and thus had made the most progress implementing their plan, we found a statistically significant reduction in the composite measure of population mental health (–0.053 change in z-score, 95% CI –0.103 to –0.002), indicating an improvement in mental health. This improvement in mental health was greater in BL areas that had spent more than 80% of their grant and prioritised social activities, while the reduction in burglaries was also larger when the analysis was limited to these BL areas and greater still in those in this group that had focused on environmental activities. For Objective 2, the impact of BL on engaged residents varied between the cohort and cross-sectional data and by subgroups. In the nested cohort there was a significant increase in mental well-being in engaged BL residents in 2018, but this was no longer statistically significant by 2020. However, this may be explained by the fact that the 2020 survey was delivered in the summer during the COVID-19 pandemic when the mental well-being of the whole country had declined. The bias created by the COVID-19 pandemic potentially affects both the outcomes and all of the explanatory variables, making interpretation of the 2020 survey data problematic. However, across all waves – even in the 2020 COVID-19 data point – residents who perceived that people in the area are willing to help each other and those who agreed that collectively they can influence decisions in the area had significantly higher mental well-being scores. Hours volunteered also had a small positive association with increased mental well-being in both the nested cohort and the repeated cross-sectional analyses, for both men and women and for groups with both high and lower levels of education. There is some evidence of unequal benefits across subgroups. For the cohort, there was a significant improvement in the mental health score in 2018 and 2020 among those with one or more degrees but not for those with ‘no degree’. In both study designs, collective control and willingness to help in the area had positive associations with mental well-being. In the repeat cross-section, residents in the lower education group who agreed that they had collective control had a higher mental well-being score in 2018 and 2020 than those who did not. In the cohort, the positive association with collective control was present for both educational groups. Together, these results suggest that the health benefits of BL participation – especially for residents with a lower level of education – may depend on whether they felt a sense of collective control. The results for gender were similarly mixed across the study designs. In the cohort, there was no significant difference in mental well-being over time for women, but men had a significant increase in the short term only (2018). In the repeat cross-section, more highly educated women had a small significant increase in mental well-being in 2020. Collective control was positively associated with higher mental well-being scores for women and – especially – men. Feeling that people in the area were willing to help was positively associated with mental well-being for women but not for men. For Objective 3, we utilised qualitative data to explore changes in collective control. Qualitative, empirical markers derived in earlier phases of CiC revealed increasing capabilities for collective control – defined as different types of power – over time. Residents in all fieldwork sites reported growing confidence in their individual and collective ability to improve the area (power within); greater understanding of the need for alliances to deliver improvements, and enhanced skills in forging and sustaining external relationships (power with); and in all these areas, meaningful improvements were delivered (power to act). Using longitudinal data, we also started to identify new qualitative markers which signalled an evolution of collective control capabilities and milestones of this evolution through three programme stages: initial implementation, developmental and bedding in. However, there was variation across BL areas. Local dynamics – internal and external to BL partnerships – could undermine residents’ ability to develop the forms of power needed to exercise collective control and also limit the potential for collective control capabilities to develop in the wider community. Without input from support workers, other professionals and local organisations, achievements in some BL areas would have been compromised. On the other hand, these actors sometimes also behaved in ways that undermined the development and exercise of collective control capabilities by residents. For Objective 4, qualitative data illuminated residents’ perceptions of BL’s impact on health and well-being. Frequent references were made to positive impacts on mental well-being at individual and collective levels. Varied pathways were identified, including improvements in social connectivity and cohesion, the physical environment and material living standards. However, there were also accounts of negative impacts on individuals, most often arising from problematic relationship dynamics and/or the burden of responsibility associated with BL partnerships, particularly with leadership roles. Residents experiencing difficulties frequently ‘stepped back’ from the partnership – sometimes temporarily, sometimes permanently. This response reflects the complex relationships many had with BL. Despite sometimes significant negative impacts, residents often also stressed positive benefits from involvement. As a national participant observed, part of the reason why community initiatives may encounter challenges or at times fail is not because people involved are ‘not thoughtful’, but because ‘being resident led is hard’. For Objective 5, the economic analysis suggests that the benefits of BL exceed its costs. The estimated benefits vary across the 150 BL areas due to variation in household income, household size and the number of residents in each area. There are also variations in the costs across BL areas. In total, the estimated annual benefits for all BL areas are £270M, so over the 4-year period from 2016 to 2019 the total benefits are £1080M. The total costs are £121M, so the net benefits are £959M. Sensitivity analyses suggest that BL’s impact on life satisfaction needs to be much lower than our current estimate before the net benefit becomes negative. Using the current impact estimate combined with the most conservative assumptions for the other elements of the cost–benefit calculations generates a net benefit estimate of £64M. Conclusions Big Local has spanned a decade of unprecedented cuts in public sector finances, restrictions on welfare benefits and latterly the COVID-19 pandemic. Despite this difficult context, our findings suggest that capabilities for collective control among engaged BL residents had increased considerably, and they had exercised this control to deliver demonstrable improvements in their neighbourhoods. However, the story is complex. Increases in capabilities for collective control were not always linear, and progress varied across BL partnerships. There is tentative quantitative evidence that BL improved mental health and reduced burglaries, especially in areas making the most progress in implementing plans. There is also evidence of improvement in mental well-being in resident partnership members between 2016 and 2018, though with some indication that these benefits were not equally distributed. The qualitative findings reinforce the possibility of quantifiable benefits, with residents highlighting positive social and mental health impacts through various pathways. However, there is also evidence of negative impacts on health and well-being. Using the most conservative assumptions, BL provides a 30% rate of return on the original National Lottery grant of £196,873,499. Our findings are particularly timely, with growing calls in England for a new ‘community power paradigm’ drawing on the BL model and the anticipated publication of government proposals for ‘levelling up’ policies that may extend current policies, devolving more decision-making and resources down to local people via place-based empowerment initiatives. Our findings have implications for future community empowerment initiatives. (1) Investment is needed to develop and sustain smaller-scale community associations and organisations to emerge from and work with communities. Careful targeting of this investment is crucial if the benefits of BL-type empowerment initiatives are to be distributed equally within and across communities. (2) Residents should be in the lead in defining and prioritising issues and designing solutions; they should be partners in, but not necessarily leaders of, action. (3) Local agencies should prioritise working as equal partners with communities over enabling communities to act for themselves. (4) Care needs to be taken that community-based initiatives are not held accountable to externally determined governance standards that undermine the development of capabilities for collective control. Our findings also have implications for future research evaluating community empowerment initiatives. (1) Evaluations need to be conducted over a long time frame and include a cohort of community members and comparator areas. (2) Secondary data need to be supplemented with primary data providing bespoke quantitative measures tailored to the programme. (3) Evaluations need to be sufficiently powered to detect small but important effects and to allow subgroup analyses that take account of variations in local programmes. (4) Evaluations must integrate an equity lens. (5) Evaluations should include longitudinal qualitative components. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information.

This commentary reflects on an important article by Fisher and colleagues who draw on four Australian policy case studies to examine how universal and targeted approaches or a combination can be deployed to improve health equity. They conclude that universal approaches are central to action to increase health equity, but that targeting can improve equity of access in some situations including in the context of proportionate universalism. However, we argue that although target services may provide benefits for some populations, they are often stigmatizing and fail to reach may people they aim to support. Instead of accepting the dominant discourse about the key role for targeted approaches, we argue that those committed to reduce social and health inequities should consider the potential of Equity Sensitive Universalism (ESU). This approach focuses on achieving proportionate outcomes with equally provided resources rather than proportionate inputs and provides a ‘cohesion dividend,’ increasing social solidarity.

The Health Inequalities Assessment Toolkit (HIAT) was developed to support those involved in health research to integrate a focus on health inequalities. Our study focuses on bringing together the concepts of boundary objects (BO) and brokers-as-bricoleurs to explain the implementation of the HIAT within a research capacity building programme. Exploring the extent to which (i) the HIAT operated as a BO and (ii) the ideal conditions to nurture and enhance its effectiveness during knowledge mobilisation. We employed a qualitative approach to analyse: semi-structured focus groups and telephone interviews; secondary data from an evaluation of the wider research programme within which the capacity building was situated. Data was thematically analysed incorporating the properties of a BO: meaningfulness, convergence, resonance and authenticity. Four main themes identified: (1) Generating convergence through creating a focus (2) Reconciling differences to create a common language (3) Workshop facilitators: boundary brokers-as-bricoleurs, (4) Thoughts into action. The HIAT operated as a BO, enabling individuals across the different project teams to galvanise around the issue of health inequalities, explore collaboratively and incorporate equity within service evaluations. Highlighting the importance of involving brokers with an ability to improvise and mobilise around the HIAT, using their expertise to translate and interpret across boundaries and emphasise shared goals. Reflecting on this, a modified tool with additional resources beyond socio-economic causes has been launched as a forum to consider health inequalities from diverse perspectives for use beyond UK health and social care research.

When looking at life expectancy (LE) by sex, women live longer than men in all countries. Biological factors alone do not explain gender differences in LE, and examining structural differences may help illuminate other explanatory factors. The aim of this research is to analyse the influence of gender inequality on the gender gap in LE globally. We have carried out a regression analysis between the gender gap in relativised LE and the UN Gender Inequality Index (GII), with a sensitivity analysis conducted for its three dimensions, stratified by the six World Health Organization (WHO) regions. We adjusted the model by taking into consideration gross national income (GNI), democratic status and rural population. The results indicated a positive association for the European region (ß=0.184) and the Americas (ß=0.136) in our adjusted model. Conversely, for the African region, the relations between gender equality and the LE gender gap were found to be negative (ß=-0.125). The findings suggest that in the WHO European region and the Americas, greater gender equality leads to a narrowing of the gender LE gap, while it has a contrary relationship in Africa. We suggest that this could be because only higher scores in the GII between men and women show health benefits.

BackgroundLife expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available.New research networkIn order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens.ConclusionFurther research using this framework has considerable potential to advance effective policies to advance health and equity.

BackgroundPublic health practice and efforts to improve the social determinants of health operate within a climate characterised by multiple and intersecting crises. This includes the Covid-19 pandemic as well as more protracted crises such as climate change and persistent social inequalities that impact health. We sought to understand and compare how knowledge exchange (KE) processes occur across different crises, and how knowledge on improving social determinants of health can be utilised at times of crisis to reduce health inequalities and strengthen public systems.MethodsWe conducted a scoping review to understand how KE on improving social determinants of health can occur across different types of crises (e.g. environmental, pandemics, humanitarian). Relevant studies were identified through electronic searching of Medline, EMBASE, Global Health, Scopus and Web of Science databases.ResultsWe identified 86 studies for inclusion in the review. Most studies concerned pandemic or environmental crises. Fewer studies explored KE during technical (e.g. nuclear), terror-related or humanitarian crises. This may reflect a limitation of the searches. Few studies assessed KE as part of longer-term responses to social and economic impacts of crises, with studies more likely to focus on immediate response or early recovery stages. Exchange of research evidence or data with policy or practice contextual knowledge was common but there was variation in the extent that lay (public) knowledge was included as part of KE processes.ConclusionAs ongoing crises continue with significant public health implications, KE processes should appropriately reflect the complexity inherent in crises and foreground health inequalities. Doing so could include the utilisation of systems or complexity-informed methods to support planning and evaluation of KE, a greater focus on KE to support action to address social determinants of health, and the inclusion of a plurality of knowledge-including lived experience-in planning and responding to crises.

Abstract Background Action to address the structural determinants of health inequalities is prioritized in high-level initiatives such as the United Nations Sustainable Development Goals and many national health strategies. Yet, the focus of much local policy and practice is on behaviour change. Research shows that whilst lifestyle approaches can improve population health, at best they fail to reduce health inequalities because they fail to address upstream structural determinants of behaviour and health outcomes. In health research, most efforts have been directed at three streams of work: understanding causal pathways; evaluating the equity impact of national policy; and developing and evaluating lifestyle/behavioural approaches to health improvement. As a result, there is a dearth of research on effective interventions to reduce health inequalities that can be developed and implemented at a local level. Objective To describe an initiative that aimed to mainstream a focus on health equity in a large-scale research collaboration in the United Kingdom and to assess the impact on organizational culture, research processes and individual research practice. Methods The study used multiple qualitative methods including semi-structured interviews, focus groups and workshops (n = 131 respondents including Public Advisers, university, National Health Service (NHS), and local and document review. Results utilizing Extended Normalization Process Theory (ENPT) and gender mainstreaming theory, the evaluation illuminated (i) the processes developed by Collaboration for Leadership in Applied Health Research and Care North West Coast to integrate ways of thinking and acting to tackle the upstream social determinants of health inequities (i.e. to mainstream a health equity focus) and (ii) the factors that promoted or frustrated these efforts. Conclusions Findings highlight the role of contextual factors and processes aimed at developing and implementing a robust strategy for mainstreaming health equity as building blocks for transformative change in applied health research.

Background. Local government is important for health equity because local policies often affect place‐based health, health equity, and their wider social determinants of health. In England, local governments must produce Joint Health and Wellbeing (JH&W) Strategies, outlining local strategies for health improvement. These strategies have been produced concurrently with budget cuts to local governments that are associated with adverse health and mortality outcomes. Using a novel approach, we assessed whether English local governments' strategies for place‐based health and equity help explain why some disadvantaged areas have better mortality trends than others. Methods. We sampled "Joint Health and Wellbeing" (JH&W) Strategies for 20 disadvantaged localities covering the years 2013–2017. We sampled areas to include some with larger and some with smaller budget cuts. We developed a qualitative appraisal process for scoring the extent to which JH&W strategies focused on (i) place‐based social determinants of health and (ii) health equity. Using qualitative comparative analysis, we assessed whether mortality trends might be explained by JH&W scores or wider contextual factors such as budget cuts, population age, and disadvantage. Results. JH&W strategies on place‐based social determinants of health and equity were often underdeveloped. Only a minority of strategies were highly rated (i.e., scoring >2 out of 3) for addressing social inequalities of health (n = 6), and even fewer scored highly for place‐based social determinants of health (n = 3). Our qualitative comparative analysis found that external and contextual factors (e.g., budget cuts and disadvantages) offer more plausible explanations than JH&W strategies for place variations in life expectancy trends. Conclusion. Budget cuts and other contextual factors better explain mortality trends than JH&W strategies. This raises concerns about what such strategies can realistically achieve in the face of structural disadvantage and national policies that restrict local spending. [ABSTRACT FROM AUTHOR]

Abstract Background While in general a country’s life expectancy increases with national income, some countries “punch above their weight”, while some “punch below their weight” – achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. Methods We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014–2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. Results Possible drivers identified for Ethiopia’s extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States’ neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. Conclusions The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

General anaesthesia (GA) is implicated as a cause of postoperative sleep disruption and fatigue with part of the disturbance being attributed to a shift of the circadian clock. In this study, Drosophila melanogaster was used as a model to determine how Isoflurane affects the circadian clock at the behavioural and molecular levels. We measured the response of the clock at both of these levels caused by different durations and different concentrations of Isoflurane at circadian time 4 (CT4). Once characterized, we held the duration and concentration constants (at 2% in air for 6 h) and calculated the phase responses over the entire circadian cycle in both activity and period expression. Phase advances in behaviour were observed during the subjective day, whereas phase delays were associated with subjective night time GA interventions. The corresponding pattern of gene expression preceded the behavioural pattern by approximately four hours. We discuss the implications of this effect for clinical and research practice.

Abstract Background The Household Health Survey (HHS) was developed to understand the socioeconomic determinants of mental and physical health, and health inequalities in health and social care. This paper aims to provide a detailed rationale of the development and implementation of the survey and explore socio-economic variations in physical and mental health and health care. Methods This comprehensive longitudinal public health survey was designed and piloted in a disadvantaged area of England, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. After piloting, the HHS was implemented across 28 neighbourhoods – 10 disadvantaged neighbourhoods for learning (NfLs), 10 disadvantaged comparator sites, and eight relatively advantaged areas, in 2015 and 2018. Participants were recruited via random sampling of households in pre-selected neighbourhoods based on their areas of deprivation. Results 7731 residents participated in Wave 1 (N = 4319) and 2 (n = 3412) of the survey, with 871 residents having participated in both. Mental health, physical health, employment, and housing quality were poorer in disadvantaged neighbourhoods than in relatively advantaged areas. Conclusions This survey provides important insights into socio-economic variations in physical and mental health, with findings having implications for improved care provision to enable residents from any geographical or socio-economic background to access suitable care.

Abstract Introduction There is an extensive literature on public involvement (PI) in research, but this has focused primarily on experiences for researchers and public contributors and factors enabling or restricting successful involvement in specific projects. There has been less consideration of a ‘whole system’ approach to embedding PI across an organization from governance structures through to research projects. Objective To investigate how a combination of two theoretical frameworks, one focused on mainstreaming and the other conceptualizing quality, can illuminate the embedding of positive and influential PI throughout a research organization. Methods The study used data from the evaluation of a large UK research collaboration. Primary data were collected from 131 respondents (including Public Advisers, university, NHS and local government staff) via individual and group interviews/workshops. Secondary sources included monitoring data and internal documents. Findings CLAHRC‐NWC made real progress in mainstreaming PI. An organizational vision and infrastructure to embed PI at all levels were created, and the number and range of opportunities increased; PI roles became more clearly defined and increasingly public contributors felt able to influence decisions. However, the aspiration to mainstream PI throughout the collaboration was not fully achieved: a lack of staff ‘buy‐in’ meant that in some areas, it was not experienced as positively or was absent. Conclusion The two theoretical frameworks brought a novel perspective, facilitating the investigation of the quality of PI in structures and processes across the whole organization. We propose that combining these frameworks can assist the evaluation of PI research.

Aphids are major pests of cereal and pasture grasses throughout the world, vectoring disease and reducing plant production. There are few control options other than insecticides. Epichloë endophytes that produce loline alkaloids in their hosts provide a possible mechanism of control, with both meadow fescue and tall fescue naturally infected with loline-producing endophytes showing a resistance to Rhopalosiphum padi. We screened Elymus spp. naturally infected with endophytes that produced loline alkaloids at concentrations known to affect aphids on fescue but found no effect on these insects infesting Elymus. A synthetic loline-producing endophyte association with rye also had no effect on the aphids. After hypothesizing that the lolines were being translocated in the xylem in Elymus and rye rather than the phloem, we tested the rye and meadow fescue infected with loline-producing endophytes against a xylem feeding spittlebug. The endophyte in rye inhibited the feeding of the insect and reduced its survival, whereas the endophyte-infected meadow fescue had no effect on the spittlebug but reduced the number of aphids. Lolines applied to the potting medium of endophyte-free and endophyte-infected rye, ryegrass, and tall fescue resulted in a decrease in the aphid populations on the endophyte-free pasture grasses relative to the untreated controls but had no effect on aphid numbers on the rye. We tentatively conclude that lolines, produced in both natural and synthetic association with Elymus and rye, are partitioned in the xylem rather than the phloem, where they are inaccessible to aphids.

SARS-CoV-2 is notable both for its rapid spread, and for the heterogeneity of its patterns of transmission, with multiple published incidences of superspreading behaviour. Here, we applied a novel network reconstruction algorithm to infer patterns of viral transmission occurring between patients and health care workers (HCWs) in the largest clusters of COVID-19 infection identified during the first wave of the epidemic at Cambridge University Hospitals NHS Foundation Trust, UK. Based upon dates of individuals reporting symptoms, recorded individual locations, and viral genome sequence data, we show an uneven pattern of transmission between individuals, with patients being much more likely to be infected by other patients than by HCWs. Further, the data were consistent with a pattern of superspreading, whereby 21% of individuals caused 80% of transmission events. Our study provides a detailed retrospective analysis of nosocomial SARS-CoV-2 transmission, and sheds light on the need for intensive and pervasive infection control procedures.

Both adults and larvae of Listronotus bonariensis damage ryegrass (Lolium spp.), a dominant component of New Zealand pasture. Damage can be reduced by Epichloë festucae var. lolii, a biotrophic fungal symbiont of ryegrass, through the production of alkaloids with deterrent and/or toxic effects to insect herbivores including L. bonariensis. Here we report results from two pot trials and a field trial comparing endophyte strains with different alkaloid profiles that have been introduced to reduce or eliminate adverse effects on stock. Adult L. bonariensis feeding scars, number of eggs and the proportion of tillers with larval damage and the severity of that damage were recorded. Samples of pseudostem and leaf blades were analysed for alkaloids. AR1 endophyte reduced adult feeding, oviposition, and larval damage whereas AR37 had no effect on adults but was highly effective in reducing larval damage. Reduction in adult feeding and oviposition by different NEA strains was governed by concentrations of peramine and ergovaline. For plants infected with AR37, alkaloid concentrations that determined the extent of larval damage were influenced by host species and ploidy; tetraploid L. perenne was more severely damaged than its diploid equivalent; L. multiflorum cultivars were more susceptible than the L. hybridum and L. perenne cultivars. [ABSTRACT FROM AUTHOR]

The oncoprotein transcription factor MYC is a major driver of malignancy and a highly validated but challenging target for the development of anticancer therapies. Novel strategies to inhibit MYC may come from understanding the co-factors it uses to drive pro-tumorigenic gene expression programs, providing their role in MYC activity is understood. Here we interrogate how one MYC co-factor, host cell factor (HCF)–1, contributes to MYC activity in a human Burkitt lymphoma setting. We identify genes connected to mitochondrial function and ribosome biogenesis as direct MYC/HCF-1 targets and demonstrate how modulation of the MYC–HCF-1 interaction influences cell growth, metabolite profiles, global gene expression patterns, and tumor growth in vivo. This work defines HCF-1 as a critical MYC co-factor, places the MYC–HCF-1 interaction in biological context, and highlights HCF-1 as a focal point for development of novel anti-MYC therapies.

Cool season grasses associate asymptomatically with foliar Epichloë endophytic fungi in a symbiosis where Epichloë spp. protects the plant from a number of biotic and abiotic stresses. Furthermore, many grass species can accumulate large quantities of silicon (Si), which also alleviates a similar range of stresses. While Epichloë endophytes may improve uptake of minerals and nutrients, their impact on Si is largely unknown. Likewise, the effect of Si availability on Epichloë colonization remains untested. To assess the bidirectional relationship, we grew tall fescue (Festuca arundinacea) and perennial ryegrass (Lolium perenne) hydroponically with or without Si. Grasses were associated with five different Epichloë endophyte strains [tall fescue: AR584 or wild type (WT); perennial ryegrass: AR37, AR1, or WT] or as Epichloë-free controls. Reciprocally beneficial effects were observed for tall fescue associations. Specifically, Epichloë presence increased Si concentration in the foliage of tall fescue by at least 31%, regardless of endophyte strain. In perennial ryegrass, an increase in foliar Si was observed only for plants associated with the AR37. Epichloë promotion of Si was (i) independent of responses in plant growth, and (ii) positively correlated with endophyte colonization, which lends support to an endophyte effect independent of their impacts on root growth. Moreover, Epichloë colonization in tall fescue increased by more than 60% in the presence of silicon; however, this was not observed in perennial ryegrass. The reciprocal benefits of Epichloë-endophytes and foliar Si accumulation reported here, especially for tall fescue, might further increase grass tolerance to stress.