Search

Objective:To understand the key mechanisms that support healthy dietary habits promoted by fruit and vegetable (F&V) box schemes, testing relevant behaviour change triggers identified under the COM-B model in an evaluation research study of a Portuguese F&V box scheme (PROVE).Design:Correlation study with a post-test-only non-equivalent group design based on survey data. The mechanisms underpinning the differences between subscribers and non-subscribers are operationalised as mediation effects. Data availability, theoretical relevance and empirical validation supported the selection and testing of four potential mediators for the effects of subscribing to the box scheme on F&V consumption. These estimations derive from the coefficients of a structural equation model combined with the product coefficient approach and Sobel test.Setting:The study is part of a wider evaluation study on the impact of the PROVE box scheme on sustainability, health and equity.Participants:A sample of PROVE box subscribers (n 294) was compared with a matched subsample of non-subscribers (n 571) in a nationally representative survey.Results:Subscribing to the PROVE box correlates with an increased probability of eating at least five portions of F&V, irrespective of differences in age, education and perceived economic difficulties. Diet quality perceptions, and more robustly, the strength of meal habits and household availability were identified as relevant mediators.Conclusions:The subscription to an F&V box scheme is connected with proximal context that enables the consumption of F&V by ensuring more readily available F&V and better situational conditions associated with healthier meal habits.

This chapter applies the conceptual framework of the social determinants of health to discuss determinants of mental health across the life course. The health and well-being of individuals is strongly influenced by social determinants. Social determinants of health (SDH) encompass wider social, economic, environmental, cultural, and political factors that shape health-related behaviours and physical and mental health outcomes. SDH can be summarized as the conditions in which people are born, grow, live, work, and age. Systematic inequalities within societies create differential experiences of social determinants across the life course, and an accumulation of positive and negative effects of social determinants shape inequalities in health. The conceptual framework describes structural factors, political, and economic factors across the lifespan. The schooling, work environment, and natural and built environment, including housing, are important factors in good health. The impact of social factors on health, including mental health, is well recognized. The relationship between physical health and mental health is bidirectional. Psychosocial factors such as work stress affect mental health. Having control over aspects of life underpins how individuals cope with stressors and is key to mental health and well-being.

Background Women with pre-existing Type 1 and Type 2 diabetes are around four times more likely to experience baby loss: miscarriage, stillbirth, neonatal death or termination of pregnancy for medical reasons. Careful pre-pregnancy preparation can reduce the risk of loss. However, pre-pregnancy information does not talk about the challenges of becoming pregnant again after a baby has died, and uptake of pre-pregnancy care is low. Approximately 50% of women with diabetes do not prepare for pregnancy - even after baby loss. There is a gap in understanding of how postnatal bereavement support should consider the context of diabetes and link with pre-pregnancy support for a subsequent pregnancy. Aim To explore and better understand: (i) what it was like for women with diabetes to become pregnant again after baby loss; (ii) healthcare professional perspectives of providing pre-pregnancy care to this group. Key Objective Develop recommendations for good practice to improve the support provided after a baby loss and improve preparation for future pregnancies among women with diabetes. Methods Health professionals and women with diabetes were recruited for an interview through social media and professional networks. Recruitment is ongoing, with an anticipated sample size of 15–20 participants per group. Semi-structured interviews were used to gain in-depth experiential insights from both patient and healthcare perspectives. Interview transcripts were systematically analysed and synthesised using Thematic Analysis. Data collection and analyses are ongoing. Results Early findings suggest individual needs differ depending on the type of diabetes and the type of loss. The influence of physical and social environments, such as living and working conditions, education level, employment status and access to transport, impact both the accessibility of care and the level of agency women with diabetes have to make the required lifestyle changes to prepare for pregnancy. Easy access to timely pre-pregnancy support from a multidisciplinary team and a sensitive discussion of pregnancy plans could reduce the risk of loss in a subsequent pregnancy. It is unclear who is responsible for supporting women in the interval between baby loss and subsequent pregnancy, and care varies across providers. Primary, community and secondary care all play a role in ensuring women with diabetes can access the care they need. Conclusion These preliminary findings shine a new light on the challenges of becoming pregnant after a baby loss and the health service requirements for this group. Further interviews and analysis will help inform care development for women with diabetes and develop social science understanding of baby loss more generally.

Background The National Health Service diabetes prevention programme in England, (NHS DPP) aims to identify people at high risk of type 2 diabetes (T2D) and offer them a face-to-face, group-based, behaviour change intervention for at least 9 months. The NHS DPP was rolled out in phases. We aimed to elicit stakeholders’ perceptions and experiences of the factors influencing implementation of, and participation in, the programme during the development phase. Methods Individual, semi-structured telephone interviews were conducted with 50 purposively sampled stakeholders: service users (n = 20); programme commissioners (n = 7); referrers (n = 8); and intervention deliverers (n = 15). Topic guides were structured using a pragmatic, theory-informed approach. Analysis employed the framework method. Results We identified factors that influenced participation: Risk communication at referral - stakeholders identified point of referral as a window of opportunity to offer brief advice, to provide an understanding of T2D risk and information about the programme; Perceived impact of the NHS DPP - service users highlighted the positive perceived impact on their behaviour change, the peer support provided by participating in the programme, the option to involve a relative, and the ‘knock on’ effect on others. Service users also voiced disappointment when blood test results still identified them at high risk after the programme; and Behavioural maintenance - participants highlighted the challenges linked to behavioural maintenance (e.g. discontinuation of active support). Factors influencing implementations were also identified: Case finding – stakeholders suggested that using community involvement to identify service users could increase reach and ensure that the workload was not solely on GP practices; Adaptability: intervention deliverers acknowledged the need to tailor advice to service users’ preferences and needs; Accountability – the need to acknowledge who was responsible for what at different stages of the NHS DPP pathway; and Fidelity – stakeholders described procedures involved in monitoring service users’ satisfaction, outcome data collection and quality assurance assessments. Conclusions The NHS DPP offers an evidence-informed behavioural intervention for T2D prevention. Better risk communication specification could ensure consistency at the referral stage and improve participation in the NHS DPP intervention. Cultural adaptations and outreach strategies could ensure the NHS DPP contributes to reducing health inequalities.

Background Smoking during pregnancy has serious consequences for maternal and child health. An intervention package to embed National Institute for Health and Care Excellence guidance (babyClear©) was delivered across maternity and stop smoking services (SSS) within an English region, to support pregnant women to stop smoking. We aimed to ascertain acceptability among pregnant smokers receiving the intervention. Methods Pregnant smokers who received the intervention and participated in the study were interviewed, first at around 16 weeks of pregnancy (n = 17) and again several weeks later (n = 8) or postpartum (n = 3). Interview schedules were informed by Normalization Process Theory (NPT) and Theoretical Domains Framework; interviews were audio-recorded, transcribed and analysed thematically, using the Framework method and NPT. Findings are grouped according to the four NPT concepts. Results Coherence: Carbon monoxide monitoring appeared to make sense; women were motivated to quit by being monitored. Cognitive participation: When linked to a professional discourse of caring and concern, some women were prompted to engage with the SS message. Women were more guarded in their reaction to initial contact from the SSS; reporting attending appointments successfully, or in some cases, experiencing problems that decreased engagement and made quitting harder. Collective action: Where women continued to smoke or failed to attend SSS appointments, an extra intervention was delivered, the Risk Perception Tool (RPT), which often prompted pregnant women to act. Reflexive monitoring: Most women accepted the need for a hard-hitting approach (RPT) and, while it distressed them at the time, they claimed they were subsequently grateful for it. SSS intervention post-RPT was seen as supportive, partly because it often involved home visits. Aspects of family inclusion in babyClear© were reported as beneficial. In Trusts where women experienced services as less focused on prioritising the stop smoking message, less well integrated or reported maternity staff as less adept at delivering the RPT, women found babyClear© less acceptable overall. Conclusions The babyClear© package was acceptable to pregnant smokers interviewed during and shortly after pregnancy and, in some cases, to promote quitting. However, some contexts were more optimal than others, leading to variation in acceptability overall.

The Social Determinants of Health (SDHs) are well known for their interaction on health outcomes and they can have a stronger impact on migrant health whom have higher probability to live in precarious living and working conditions compared to the hosting population. Migrant health is a public health issue which has to be considered taking into account the SDHs and complementary, including cultural issues is fundamental for addressing health equity in the society as a whole. Recognising this challenge, this study aims to evaluate the interactions between education and mental health of resident population in Italy, including Italians and immigrants. This study examined the respondents in 2014-17 to the Italian “Progressi delle Aziende Sanitarie per la Salute in Italia” (PASSI) surveillance system. The sample of 118,639 respondents is composed by the residing working adults aged 25-69 with Italian citizenship (n = 112,345) and foreign citizenship (n = 6,294). Looking at SDHs, if for Italians high level of education appears to be a protective factor of mental health in accordance with the international evidence (adjPR: tertiary education 0,87 95%IC 079-0,97), among immigrants higher level of education it is more associated with the presence of depressive symptoms (adjPR: tertiary education: 1.77 95%IC: 1.19-2.63). Longer the length of stay in Italy for PFPM immigrants higher the risk of depressive symptoms: adjPR for 10+ years: 5.1 95%IC: 1.29-4.3. The data show that high education could represent a risk factor for mental health of immigrants. Considering that health is related to the nature of society as well as to access to technical solutions, multicultural societies require culturally oriented interventions for tackling health inequities. This means developing evidence-based policies in order to tackle health inequalities in the population as a whole, including culturally oriented measures in the larger framework of developing diversity sensitive services. Key messages For some groups of population, such as migrants, high education could represent a risk factor for mental health. Developing diverse sensitive policies is needed in order to tackle health inequities in the population as a whole.

The opening up of green spaces could provide significant benefits to society. This study develops a framework to assess the economic benefits and costs of public interventions providing citizen access to urban green spaces. The Thinking Fadura project in Getxo (Spain) was used as a case study. A method for participatory benefit-cost analysis is developed, where a stakeholder-participatory evaluation is combined with a standard cost-benefit analysis. The participatory evaluation followed a bottom-up approach in a sequential evaluation including three main focal points: key stakeholders and experts, visitors and the general public. The assessment demonstrates that the Thinking Fadura project&rsquo, s benefits outweigh the costs. The results suggest that projects designed with the purpose of improving green space accessibility to the general public can be beneficial from a societal perspective. The highest economic benefits were an increase in the amenity and recreational value and an increase in people&rsquo, s physical activity. The participatory evaluation indicates that giving access to people of lower socio-economic status and vulnerable groups and improving recreational use were perceived as the most beneficial. An increase in noise, dirt, and risk of criminal activities as well as potential conflicts between green space users were perceived as the most negative impacts of opening a previously restricted area to the general public. The economic assessment of Thinking Fadura project could serve as a model in the decision-making process in locations where the use of greenspaces is restricted.

ObjectiveTransjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat the sequelae of portal hypertension, including refractory variceal bleeding, ascites and hepatic hydrothorax. However, hernia-related complications such as incarceration and small bowel obstruction can occur after TIPS placement in patients with pre-existing hernias. The aim of this study was to determine the incidence of hernia complications in the first year after TIPS placement and to identify patient characteristics leading to an increased risk of these complications.DesignThis retrospective analysis included patients with pre-existing abdominal hernias who underwent primary TIPS placement with covered stents at our institution between 2004 and 2018. The 1-year hernia complication rate and the average time to complications were documented. Using a Wilcoxon rank-sum test, the characteristics of patients who developed hernia-related complications versus the characteristics of those without complications were compared.ResultsA total of 167 patients with pre-existing asymptomatic abdominal hernias were included in the analysis. The most common reason for TIPS placement was refractory ascites (80.6%). A total of 36 patients (21.6%) developed hernia-related complications after TIPS placement, including 20 patients with acute complications and 16 with non-acute complications. The mean time to presentation of hernia-related complications was 66 days. Patients who developed hernia-related complications were more likely than those without complications to have liver cirrhosis secondary to alcohol consumption (p=0.049), although this association was no longer significant after multivariate analysis.ConclusionWithin 1 year after TIPS placement, approximately 20% of patients with pre-existing hernias develop hernia-related complications, typically within the first 2 months after the procedure. Patients with pre-existing hernia undergoing TIPS placement should be educated regarding the signs and symptoms of hernia-related complications, including incarceration and small bowel obstruction.

Aims/hypothesis: The aim of this prospective nationwide study was to examine antenatal pregnancy care and pregnancy outcomes in women with type 1 and type 2 diabetes, and to describe changes since 2002/2003. Methods: This national population-based cohort included 3036 pregnant women with diabetes from 155 maternity clinics in England and Wales who delivered during 2015. The main outcome measures were maternal glycaemic control, preterm delivery (before 37 weeks), infant large for gestational age (LGA), and rates of congenital anomaly, stillbirth and neonatal death. Results: Of 3036 women, 1563 (51%) had type 1, 1386 (46%) had type 2 and 87 (3%) had other types of diabetes. The percentage of women achieving HbA1c < 6.5% (48 mmol/mol) in early pregnancy varied greatly between clinics (median [interquartile range] 14.3% [7.7–22.2] for type 1, 37.0% [27.3–46.2] for type 2). The number of infants born preterm (21.7% vs 39.7%) and LGA (23.9% vs 46.4%) were lower for women with type 2 compared with type 1 diabetes (both p < 0.001). The prevalence rates for congenital anomaly (46.2/1000 births for type 1, 34.6/1000 births for type 2) and neonatal death (8.1/1000 births for type 1, 11.4/1000 births for type 2) were unchanged since 2002/2003. Stillbirth rates are almost 2.5 times lower than in 2002/2003 (10.7 vs 25.8/1000 births for type 1, p = 0.0012; 10.5 vs 29.2/1000 births for type 2, p = 0.0091). Conclusions/interpretation: Stillbirth rates among women with type 1 and type 2 diabetes have decreased since 2002/2003. Rates of preterm delivery and LGA infants are lower in women with type 2 compared with type 1 diabetes. In women with type 1 diabetes, suboptimal glucose control and high rates of perinatal morbidity persist with substantial variations between clinics. Data availability: Further details of the data collection methodology, individual clinic data and the full audit reports for healthcare professionals and service users are available from http://content.digital.nhs.uk/npid.

Objective to investigate barriers and facilitators to physical activity (PA) guideline implementation for midwives when advising obese pregnant women. Design a cross-sectional, self-completion, anonymous questionnaire was designed using the Theoretical Domains Framework. this framework was developed to evaluate the implementation of guidelines by health care professionals. A total of 40 questions were included. These were informed by previous research on pregnant women's and midwives views, knowledge and attitudes to PA, and supported by national evidence based guidelines. Demographic information and free text comments were also collected. Setting three diverse NHS Trusts in the North East of England. Participants all midwives employed by two hospital Trusts and the community midwives from the third Trust ( n =375) were invited to participate. Measurements mean domain scores were calculated. Factor and regression analysis were performed to describe which theoretical domains may be influencing practice. Free text comments were analysed thematically. Findings 192 (53%) questionnaires were returned. Mean domain scores were highest for social professional role and knowledge, and lowest for skills, beliefs about capabilities and behaviour regulation. Regression analysis indicated that skills and memory/attention/decision domains had a statistically significant influence on midwives discussing PA with obese pregnant women and advising them accordingly. Midwives comments indicated that they felt it was part of their role to discuss PA with all pregnant women but felt they lacked the skills and resources to do so effectively. Key conclusions midwives seem to have the necessary knowledge about the need/importance of PA advice for obese women and believe it is part of their role, but perceive they lack necessary skills and resources, and do not plan or prioritise the discussion regarding PA with obese pregnant woman. Implications for practice designing interventions that improve skills, promote routine enquiry regarding PA and provide resources (eg. information, referral pathways) may help improve midwives' PA advice.

Objectives:Randomised controlled trials are required to address causality in the reported associations between maternal influences and offspring adiposity. The aim of this study was to determine whether an antenatal lifestyle intervention, associated with improvements in maternal diet and reduced gestational weight gain (GWG) in obese pregnant women leads to a reduction in infant adiposity and sustained improvements in maternal lifestyle behaviours at 6 months postpartum.Subjects and methods:We conducted a planned postnatal follow-up of a randomised controlled trial (UK Pregnancies Better Eating and Activity Trial (UPBEAT)) of a complex behavioural intervention targeting maternal diet (glycaemic load (GL) and saturated fat intake) and physical activity in 1555 obese pregnant women. The main outcome measure was infant adiposity, assessed by subscapular and triceps skinfold thicknesses. Maternal diet and physical activity, indices of the familial lifestyle environment, were assessed by questionnaire.Results:A total of 698 (45.9%) infants (342 intervention and 356 standard antenatal care) were followed up at a mean age of 5.92 months. There was no difference in triceps skinfold thickness z-scores between the intervention vs standard care arms (difference −0.14 s.d., 95% confidence interval −0.38 to 0.10, P=0.246), but subscapular skinfold thickness z-score was 0.26 s.d. (−0.49 to −0.02; P=0.03) lower in the intervention arm. Maternal dietary GL (−35.34; −48.0 to −22.67; P

Green space areas offer several benefits that support our physical, psychological, and social health. However, the level of engagement with green space areas may not be the same across population groups. Using a mixed-method research design, we investigated the use of a green space area and whether and how the area was beneficial for health, social inclusion, and physical activity for all socioeconomic groups in a suburban area in Norway. The study showed significantly increased use of the area from 2015&ndash, 2018 and that users belonged to different socioeconomic groups. The motivation for using the area was the opportunity to experience nature and to interact socially. While no significant changes in self-rated health, life satisfaction, or levels of physical activity were found, the study indicates that factors such as location, availability, and designated places for social interaction are important motivating factors for use. Users from the lower socioeconomic groups were among the frequent users but were also the least satisfied with the quality and availability of the path. Our findings call for closer consideration of the location and availability of green spaces and that including places for social interaction and relaxation can contribute to increased use of green spaces.

Invite the world to dream. That is what the United Nations (UN) did in 2012 through launching its unprecedented global consultation for the Sustainable Development Goals (SDGs) under the banner “the world we want.”1 Three years later, after extensive consultations and negotiations among multiple stakeholders, country leaders at the UN General Assembly in December 2015 agreed upon 17 Sustainable Development Goals (SDGs), listed below, under the overarching principle of “leaving no one behind.”

ObjectivesTo synthesise the findings of qualitative research exploring parents’ experiences, views and decisions about becoming pregnant following a perinatal death or fetal loss.DesignSystematic review and meta-synthesis of qualitative research.Data sourcesMedline, Web of Science, CINAHL, PsycINFO, ASSIA, Embase, PUBMED, Scopus and Google Scholar.Eligibility criteriaNine electronic databases were searched using predefined search terms. Articles published in English, in peer-reviewed journals, using qualitative methods to explore the experiences and attitudes of bereaved parents following perinatal or fetal loss, were included.Data extraction and synthesisQualitative data relating to first-order and second-order constructs were extracted and synthesised across studies using a thematic analysis.Results15 studies were included. Four descriptive themes and 10 subthemes were identified. The descriptive themes were: deciding about subsequent pregnancy, diversity of reactions to the event, social network influences, and planning or timing of subsequent pregnancy. The decision to become pregnant after death is complex and varies between individuals and sometimes within couples. Decisions are often made quickly, in the immediate aftermath of a pregnancy loss, but may evolve over time. Bereaved parents may feel isolated from social networks.ConclusionsThere is an opportunity to support parents to prepare for a pregnancy after a fetal or perinatal loss, and conversations may be welcomed at an early stage. Health professionals may play an important role providing support lacking from usual social networks.PROSPERO registration numberCRD42018112839

The world&rsquo, s challenges of climate change, damage to ecosystems, and social and health inequalities require changes in human behaviours at every level of organisation, among governments, business, communities, and individuals. An important question is how behaviour change can be enabled and supported at the scale and speed required. The research reported in this paper describes important lessons for good practice in changing contexts to modify behaviours for a triple win for health, equity and environmental sustainability. Authors synthesised learning from qualitative, quantitative and cost benefit evaluations of 15 case studies conducted in 12 countries in Europe. The case studies address ways of living (green spaces and energy efficient housing), moving (active transport) and consuming (healthy and sustainable diets) that support the triple win. Ten lessons for good practice were identified. These include bringing a triple win mindset to policy and practice in planning interventions, with potential to improve environmental sustainability, health and equity at the same time. The lessons for good practice are intended to support governmental and non-governmental actors, practitioners and researchers planning to work across sectors to achieve mutual benefits for health and environmental sustainability and in particular to benefit poorer and more socio-economically disadvantaged groups.

The need to act on climate change, and to modify how we live, move and consume is urgent; failure to do so will have catastrophic effects on health and wellbeing over the medium and long term. INHERIT, a large multi-sectoral research initiative (2016-2019) has explored what can be done to seize this as an opportunity to encourage and enable people to modify their behaviours towards ones that simultaneously protect the environment and promote health and health equity (the ‘INHERIT triple-win’). One strand of INHERIT’s work has involved the identification, implementation and evaluation (qualitative, quantitative and cost-benefit) of 15 promising ‘triple-win’ interventions across the EU. INHERIT has also developed four positive scenarios of more sustainable futures, questioned 183 people about these, and surveyed 10,288 people from five countries across the EU about their current behaviours and incentives for change. The results of these investigations paint a complex picture of what can be done to encourage and enable more people across the socio-economic gradient to adapt their behaviours. They reflect that improving health is a powerful motivator for action to protect the environment, yet there is often confusion about what is considered ‘sustainable’, whether this is always ‘healthy’ and vice-versa, let alone equitable. There is resistance in some countries to modifying some behaviours, like meat consumption. Many people fear that technological solutions will drive up isolation and inequities, and desire stronger community ownership over processes like food and energy production. INHERIT outcomes reflect that it is possible to conjure common visions of the kinds of societies we want to transition to, and a willingness and potential to work across sectors to achieve these. This requires stronger individual and collective leadership, also from public health actors, who can play a key role in bringing together different actors and sectors to achieve these visions. Key messages The urgent need to address the environmental crisis presents an opportunity to simultaneously manage closely related societal challenges linked to health and equity. Public health actors can play a key role by bringing together the sectors, evidence and examples to instigate change, around the common interest of promoting human, which depends on planetary, health.

Background: Mental health can help explain how social inequalities impact on health. Many current public health challenges are shaped by social, economic and environmental conditions that take a mental toll on society. Purpose: This article describes a conceptual framework illustrating the psychosocial pathways that link the wider conditions to health behaviours and outcomes. It draws out implications of this framework for mental health practice that aim to support policy and decision-making on future action to reduce health inequalities and presents practical examples of what can be done. Methods: This article expands on a report commissioned by Public Health England. A narrative review and synthesis of relevant evidence built on existing research by the Institute of Health Equity. A conceptual framework was developed and a consultation exercise with stakeholders helped to revise and illustrate it with practice examples. Conclusions: The field of mental health has much to contribute to prevention, not just of mental illness but also of physical health conditions and reduction of inequalities in life expectancy and healthy life expectancy, especially through collaborative public health action.

A whole systems approach that integrates action on the social determinants of health is essential to reduce the burden of non-communicable disease, argue Michael Marmot and Ruth Bell

Urbanization, costs of green space maintenance, and diminishing connection between people and nature all exert pressures on urban green space. This is regrettable as green space has the potential to create wins for environmental sustainability, health, and health equity. This paper explores this potential triple win and investigates how to increase the use of urban green space through behavior change. A narrative literature review was conducted and was supplemented with literature suggested by experts. Results show that creating well-designed green spaces and stimulating people to use them can indeed deliver this triple win. Providing accessible, attractive, well-maintained green space with room for socialization, and where people feel safe, may increase the opportunity and motivation of people to use it more often. Informing and educating people and organizing activities may increase capability (and motivation) to use green space. Since the use of green space depends on life stage, lifestyle factors and individual values, it is important to involve potential users in its design. We recommend a specific focus on those groups who may benefit most from the use of green space. More evaluation is needed to inform effective green space interventions and to assess related economic, social, and environmental benefits. © 2019 by the authors. Licensee MDPI, Basel, Switzerland. The work presented in this paper was funded by the European Union’s Horizon 2020 research and innovation program under grant agreement no. 667364.

Introduction The paper describes and examines a novel methodology to co-define transport and mobility challenges and co-create solutions with residents of a socioeconomically disadvantaged area within Oxford in the UK. The co-creation methodology is examined in relation to the extent of participation, inclusivity, transparency, interactivity, scale, sustainability/continuity, replicability, potential for co-benefits. Methods A Citizen Mobility Community was established with local residents at the core, and including representatives from the local authority, and other stakeholders. The paper describes the main elements of the co-creation process applied to identify mobility challenges, identify solutions, endorse the mobility solutions, and develop the solutions into practical action. Setting The setting was the Eastern Arc of Oxford, the most socioeconomically deprived area in Oxford. Results A sequence of co-creation activities helped identify and understand the transport challenges in Barton in the Eastern Arc of Oxford. Challenges included the high cost of public transport, traffic congestion, particularly during morning peak times, and the lack of cross-connectivity and direct public transport routes to desirable locations including affordable supermarkets, train stations, workplaces, health services such as hospitals and other neighbourhoods. The co-creation methodology led to the development of three pilot interventions to address these challenges, namely face-to-face transport app training, a transport to supermarkets shuttle service, and an information campaign about concessionary bus passes. Analysis of the co-creation methodology found that the process achieved its aims of empowering citizens in decision making about addressing locally experienced transport challenges, and building social capital. Conclusions The co-creation enables communities in areas of socioeconomic disadvantage to identify their transport challenges, and to co-develop and co-design practical solutions. Co-creation to address local transport needs builds community empowerment, creates social capital and may contribute, through plausible causal pathways, to improved health and wellbeing in an area of socioeconomic disadvantage.

INTRODUCTION The incidence of pregnancies complicated by twinning and diabetes is increasing in the UK. This is a worrying trend as both diabetes and twin gestations are associated with a high risk of adverse pregnancy outcomes. The few studies that have specifically addressed how twinning and pregestational diabetes in the same pregnancy may affect outcome have reported conflicting results. MATERIAL AND METHODS We analyzed data on 27 women with a twin pregnancy and pregestational diabetes (54 babies) and 6407 women with a twin pregnancy without diabetes (12 814 babies) from the Northern Survey of Twin and Multiple Pregnancy during 1998-2010. A composite adverse pregnancy outcome (comprising fetal loss before 24 weeks, termination of pregnancy, stillbirth, infant death or any major congenital anomaly), extended perinatal mortality (stillbirths and neonatal deaths) and major congenital anomaly were the main outcome measures. Adjusted rate ratios were estimated using generalized estimating equations for Poisson regression controlling for potential confounders. RESULTS Mothers with twin pregnancies with diabetes were older (p = 0.001) and had higher body mass indices (p < 0.0001) than those without diabetes. Their twins were more likely to be delivered earlier (p = 0.026), be delivered by cesarean section (80.4% vs. 49.7%; p < 0.0001), be large-for-gestational-age (p < 0.0001) and require admission to a special care baby unit (p < 0.0001). Pregestational diabetes was associated with significantly increased rates of the composite adverse outcome and major congenital anomalies in twins (adjusted rate ratios 2.66, 95% confidence interval 1.14-6.20 and adjusted rate ratios 3.51, 95% confidence interval 1.31-9.40, respectively). CONCLUSION Maternal pregestational diabetes in twin pregnancies is associated with a significantly increased risk of an adverse pregnancy outcome.

Human consumption and activity are damaging the global ecosystem and the resources on which we rely for health, well-being and survival. The COVID-19 crisis is yet another manifestation of the urgent need to transition to more sustainable societies, further exposing the weaknesses in health systems and the injustice in our societies. It also underlines that many of the factors leading to environmental degradation, ill health and social and health inequities are interlinked. The current situation provides an unprecedented opportunity to invest in initiatives that address these common factors and encourage people to live more healthily and sustainably. Such initiatives can generate the positive feedback loops needed to change the systems and structures that shape our lives. INHERIT (January 2016–December 2019), an ambitious, multisectoral and transnational research project that involved 18 organisations across Europe, funded by the European Commission, explored such solutions. It identified, defined and analysed promising inter-sectoral policies, practices and approaches to simultaneously promote environmental sustainability, protect and promote health and contribute to health equity (the INHERIT “triple-win”) and that can encourage and enable people to live, move and consume more healthfully and sustainably. It also explored the facilitators and barriers to working across sectors and in public private cooperation. The insights were brought together in guidelines setting out how policy makers can help instigate and support local “triple-win” initiatives that influence behaviours as an approach to contributing to the change that is so urgently needed to stem environmental degradation and the interlinked threats to health and wellbeing. This article sets out this guidance, providing timely insights on how to “build back better” in the post pandemic era.

Metastatic breast cancer (mBC) continues to be a leading cause of cancer-related death in women. Even though mortality rates have improved over recent years, the 5-year survival rate of advanced BC is still at only 27%. As researchers and clinicians attempt to tackle this challenge, there has been extensive research and many trials studying treatment options for BC patients with metastatic disease, with numerous new therapies being discovered as a result. We review the most pertinent novel agents to enter the scope of BC treatment, including CDK4/6 inhibitors, PI3K inhibitors, mTOR inhibitors, immunotherapy, PARP inhibitors, and more.

The STOEMP network is, to our knowledge, one of the first initiatives to bring different sectors together in a municipality so as to increase accessibility to healthy and sustainable foods for all, with particular attention for the disadvantaged population. This qualitative study aimed to gain an in-depth insight into how the STOEMP network aims to reach its goal of making healthy, sustainable food available to everyone, through an intersectoral, collaborative process, exploring the facilitators and challenges of taking a systems-oriented approach to achieving this. Interviews were conducted among 15 stakeholders of the STOEMP network between March&ndash, July 2019 in Ghent (Belgium). Factors that facilitated the development and work of the network are reported, including having an external, neutral process manager, shared values, multisector engagement, enthusiasm, resources, and sense of ownership, as well as the barriers that were faced, such as time issues, uncertainty regarding continuation and funding, and discrepancy in visions. These issues reflect the strengths and challenges of taking a systems approach that aims to formulate solutions to widening access to healthy and sustainable foods. STOEMP would like to influence policy and thereby strengthen its impact, but needs further discussions to collectively formulate exact needs.

BackgroundDisability rates increase with age. In 2012, Peruvian older adults (≥ 65 years) represented 9% of the population. Additionally, older population reported disabilities at about 5 times the rate of Peruvians between 36 and 64 years old, and 30% of older population lived in poverty. Peruvian seniors living in extreme poverty experience disabilities and the extent of their access to healthcare is unknown.ObjectiveThis study assesses associations between disability and access to healthcare among Peruvians older individuals living in extreme poverty.MethodsSecondary analysis of a national representative population based survey that utilizes information from Peru's 2012 survey Health and Wellbeing in Older Adults (ESBAM), which includes older adults living in extreme poverty. We define disability in terms of the Activities of Daily Living (ADL disability) framework. Healthcare access was assessed as having any of Peru's available health insurance schemes combined with preventive health services (vision assessment, influenza vaccination, blood pressure assessment, diabetes screening, and cholesterol assessment). Poisson robust regression models were used to evaluate the associations among relevant variables. Prevalence Ratios and 95% confidence intervals (95%CI) were reported.ResultsData from 3869 individuals (65 to 80 years old), of whom 1760 (45.5%) were females, were analyzed. The prevalence of ADL disability was 17.3% (95%CI: 16.0%-18.4%). In addition, more than 60% had never received any of the preventive measures evaluated, except for the blood pressure assessment. In the adjusted model, people with ADL disability had 63% less probability of having extensive insurance, compared to those without disability (pConclusionsThis study shows that this Peruvian older population living in extreme poverty has limited access to healthcare services. Although there was no consistent association between ADL disability and the healthcare access, there is an urgent need to reduce the inequitable access to healthcare of this poor Peruvian older population.

This chapter discusses evidence linking social inequalities, across social, economic, and environmental dimensions to inequalities in mental health. A framework for thinking about the lifetime causes of inequalities in mental health is presented and used to discuss how experiences and conditions affect mental health across the life course. The chapter focuses particularly on factors that affect child development because of the importance of child developmental outcomes for future mental and physical health, and on life chances. Finally, the need for more attention to be focused on addressing the causes of social inequalities in mental health through multiple types of policies and interventions is discussed.