Assessment of COVID-19 outbreaks in long-term care facilities

BACKGROUND

The B.1.167.2 (Delta) variant quickly became the predominant circulating SARS-CoV-2 strain in the USA during summer 2021. Missouri identified a high number of outbreaks in long-term care facilities (LTCFs) across the state with low vaccination rates among LTCF staff members and poor adherence to mitigation measures within local communities.

AIM

To describe COVID-19 outbreaks that occurred in Missouri LTCFs impacting staff and residents during the surge of the Delta variant.

METHODS

Outbreaks of COVID-19 in 178 LTCFs were identified by the Missouri Department of Health and Senior Services. Case data from LTCFs with the highest burden of disease were analysed to assess disease transmission, vaccination status, and outcomes among residents and staff. Additional investigational measures included onsite visits to facilities with recent COVID-19 outbreaks in communities with substantial transmission to assess mitigation measures.

FINDINGS

During April 22^nd to July 29^th, 2021, 159 COVID-19 cases among 72 staff members and 87 residents were identified in 10 LTCFs. More than 74.7% of resident cases were vaccinated compared to 23.6% of staff cases. Vaccinated residents had a lower proportion of hospitalizations and deaths reported compared to unvaccinated residents. Data analysis and contact-tracing efforts from a sample of the facilities suggest that staff members were likely a major factor in introducing SARS-CoV-2 virus into the facilities. Adherence to COVID-19 mitigation measures varied at the visited facilities.

CONCLUSION

Data showed that vaccination rates varied between staff cases and resident cases in facilities with high-burden outbreaks. Differences were identified in mitigation practices in at least two facilities.

Standardizing Electronic Health Record Data on AD/ADRD to Accelerate Health Equity in Prevention, Detection, and Treatment

Improving the prevention, detection, and treatment of Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) across racial, ethnic, and other diverse populations is a national priority. To this end, this paper proposes the development of the Standard Health Record for Dementia (SHRD, pronounced "shared") for collecting and sharing AD/ADRD real-world data (RWD). SHRD would replace the current unstandardized, fragmented, or missing state of key RWD with an open source, consensus-based, and interoperable common data standard. This paper describes how SHRD could leverage the best practices of the Minimal Common Oncology Data Elements (mCODETM) initiative to advance prevention, detection, and treatment; gain adoption by clinicians and electronic health record (EHR) vendors; and establish sustainable business and governance models. It describes a range of potential use cases to advance equity, including strengthening public health surveillance by facilitating AD/ADRD registry reporting; improving case detection and staging; and diversifying participation in clinical trials.

Altering product placement to create a healthier layout in supermarkets: Outcomes on store sales, customer purchasing, and diet in a prospective matched controlled cluster study

BACKGROUND

Previous product placement trials in supermarkets are limited in scope and outcome data collected. This study assessed the effects on store-level sales, household-level purchasing, and dietary behaviours of a healthier supermarket layout.

METHODS AND FINDINGS

This is a prospective matched controlled cluster trial with 2 intervention components: (i) new fresh fruit and vegetable sections near store entrances (replacing smaller displays at the back) and frozen vegetables repositioned to the entrance aisle, plus (ii) the removal of confectionery from checkouts and aisle ends opposite. In this pilot study, the intervention was implemented for 6 months in 3 discount supermarkets in England. Three control stores were matched on store sales and customer profiles and neighbourhood deprivation. Women customers aged 18 to 45 years, with loyalty cards, were assigned to the intervention (n = 62) or control group (n = 88) of their primary store. The trial registration number is NCT03518151. Interrupted time series analysis showed that increases in store-level sales of fruits and vegetables were greater in intervention stores than predicted at 3 (1.71 standard deviations (SDs) (95% CI 0.45, 2.96), P = 0.01) and 6 months follow-up (2.42 SDs (0.22, 4.62), P = 0.03), equivalent to approximately 6,170 and approximately 9,820 extra portions per store, per week, respectively. The proportion of purchasing fruits and vegetables per week rose among intervention participants at 3 and 6 months compared to control participants (0.2% versus -3.0%, P = 0.22; 1.7% versus -3.5%, P = 0.05, respectively). Store sales of confectionery were lower in intervention stores than predicted at 3 (-1.05 SDs (-1.98, -0.12), P = 0.03) and 6 months (-1.37 SDs (-2.95, 0.22), P = 0.09), equivalent to approximately 1,359 and approximately 1,575 fewer portions per store, per week, respectively; no differences were observed for confectionery purchasing. Changes in dietary variables were predominantly in the expected direction for health benefit. Intervention implementation was not within control of the research team, and stores could not be randomised. It is a pilot study, and, therefore, not powered to detect an effect.

CONCLUSIONS

Healthier supermarket layouts can improve the nutrition profile of store sales and likely improve household purchasing and dietary quality. Placing fruits and vegetables near store entrances should be considered alongside policies to limit prominent placement of unhealthy foods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03518151 (pre-results).

Adult diet in England: Where is more support needed to achieve dietary recommendations?

Background

Small-area estimation models are regularly commissioned by public health bodies to identify areas of greater inequality and target areas for intervention in a range of behaviours and outcomes. Such local modelling has not been completed for diet consumption in England despite diet being an important predictor of health status. The study sets out whether aspects of adult diet can be modelled from previously collected data to define and evaluate area-level interventions to address obesity and ill-health.

Methods

Adults aged 16 years and over living in England. Consumption of fruit, vegetables, and sugar-sweetened beverages (SSB) are modelled using small-area estimation methods in English neighbourhoods (Middle Super Output Areas [MSOA]) to identify areas where reported portions are significantly different from recommended levels of consumption. The selected aspects of diet are modelled from respondents in the National Diet and Nutrition Survey using pooled data from 2008–2016.

Results

Estimates indicate that the average prevalence of adults consuming less than one portion of fruit, vegetables or 100% juice each day by MSOA is 6.9% (range of 4.3 to 14.7%, SE 0.06) and the average prevalence of drinking more than 330ml/day of SSB is 11.5% (range of 5.7 to 30.5%, SE 0.03). Credible intervals around the estimates are wider for SSB consumption. The results identify areas including regions in London, urban areas in the North of England and the South coast which may be prioritised for targeted interventions to support reduced consumption of SSB and/or an increase in portions of fruit and vegetables.

Conclusion

These estimates provide valuable information at a finer spatial scale than is presently feasible, allowing for within-country and locality prioritisation of resources to improve diet. Local, targeted interventions to improve fruit and vegetable consumption such as subsidies or voucher schemes should be considered where consumption of these foods is predicted to be low.

Moving beyond randomized controlled trials in the evaluation of compulsory community treatment

Compulsory community treatment for people with severe mental illness remains controversial due to conflicting research evidence. Recently, there have been challenges to the conventional view that trial-based evidence should take precedence. This paper adds to these challenges in three ways. First, it emphasizes the need for critiques of trials to engage with conceptual and not just technical issues. Second, it develops a critique of trials centred on both how we can have knowledge and what it is we can have knowledge of. Third, it uses this critique to develop a research strategy that capitalizes on the information in large-scale datasets.

Twenty-five years of Health & Place: Citation classics, internationalism and interdisciplinarity

To mark 25 years of Health & Place Health & Place, we identify and appraise some key contributions to the journal over this period. We use citation data to identify 'classics' from the journal's back catalogue. We also examine trends in the international reach and disciplinary homes of our authors. We show that there has been a near 7-fold increase in the number of published papers between the early and most recent years of the journal and that the journal's citation levels are amongst the top 2% of social science journals. Amongst the most cited papers, some clear themes are evident such as physical activity, diet/food, obesity and topics relating to greenspace. The profile of the journal's authors is becoming more internationally diverse, represents a broader range of disciplines, and increasingly demonstrating cross/interdisciplinary ways of working. Although Anglophone countries have led the way, there is an increasing number of contributions from elsewhere including emerging economies such as China. We conclude with some comments on likely future directions for the journal including enduring concerns such as greenspace, obesity, diet and unhealthy commodities (alcohol, tobacco, ultra-processed food) as well as more recent directions including planetary health, longitudinal and lifecourse analyses, and the opportunities (and challenges) of big data and machine learning. Whatever the thematic concerns of the papers over next 25 years, we will continue to welcome outstanding research that is concerned with the importance place makes to health.

Humeral shaft fracture and radial nerve palsy in Korean soldiers: focus on arm wrestling related injury

INTRODUCTION

Humeral shaft fractures can lead to radial nerve injury and may require surgery and rehabilitation. We determined the causative events of humeral fracture, including arm wrestling, in young Korean soldiers and examined whether humeral fracture is related to demographic characteristics and the presence of radial nerve palsy.

METHODS

We reviewed 7.5 years (July 2012 to June 2019) of medical records covering patients who had experienced a humeral shaft fracture after entering military service and had received surgery for open reduction and internal fixation. Data were obtained on basic demographics, initial event provoking the fracture, presence of radial nerve palsy, initial and follow-up severity of the weakness, and any discharge from military service because of prolonged radial nerve palsy.

RESULTS

Of 123 cases, arm wrestling was the leading cause (52.8%). A high energy injury, such as falling from a height (11.4%), and sports related slips (10.6%) were other causes. All humeral shaft fractures caused by forceful contraction were spiral, while 40% of the fractures caused by external force related events were of a transverse type. The percentage of left-sided fractures was significantly higher for fractures arising from an external force than in those caused by forceful contraction related events. Radial nerve palsy was found in 34 patients (27.6%), and 16 were discharged from the military because of prolonged radial nerve palsy 6 months after the fracture. The causative events and other factors did not affect the presence of radial nerve palsy.

CONCLUSION

Arm wrestling was the leading cause of humeral fracture in young Korean soldiers but the chance of developing comorbid radial nerve palsy did not differ from that of other causes. These epidemiologic findings in this young active group may help in understanding the causes of humeral shaft fracture in soldiers and in the wider young population.

Protocol of a natural experiment to evaluate a supermarket intervention to improve food purchasing and dietary behaviours of women (WRAPPED study) in England: a prospective matched controlled cluster design

INTRODUCTION

Poor diet is a leading risk factor for non-communicable diseases and costs the National Health Service £5.8 billion annually. Product placement strategies used extensively in food outlets, like supermarkets, can influence customers' preferences. Policy-makers, including the UK Government, are considering legislation to ensure placement strategies promote healthier food purchasing and dietary habits. High-quality scientific evidence is needed to inform future policy action. This study will assess whether healthier placement strategies in supermarkets improve household purchasing patterns and the diets of more than one household member.

METHODS AND ANALYSES

This natural experiment, with a prospective matched controlled cluster design, is set in discount supermarkets across England. The primary objective is to investigate whether enhanced placement of fresh fruit and vegetables improves household-level purchasing of these products after 6 months. Secondary objectives will examine: (1) differences in intervention effects on purchasing by level of educational attainment, (2) intervention effects on the dietary quality of women and their young children, (3) intervention effects on store-level sales of fruit and vegetables and (4) cost-effectiveness of the intervention from individual, retailer and societal perspectives. Up to 810 intervention and 810 control participants will be recruited from 18 intervention and 18 matched control stores. Eligible participants will be women aged 18-45 years, who hold a loyalty card and shop in a study store. Each control store will be matched to an intervention store on: (1) sales profile, (2) neighbourhood deprivation and (3) customer profile. A detailed process evaluation will assess intervention implementation, mechanisms of impact and, social and environmental contexts.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Southampton, Faculty of Medicine Ethics Committee (ID 20986.A5). Primary, secondary and process evaluation results will be submitted for publication in peer-reviewed scientific journals and shared with policy-makers.

TRIAL REGISTRATION NUMBER

NCT03573973; Pre-results.

Use of community treatment orders and their outcomes: an observational study

Background

Community treatment orders are widely used in England. It is unclear whether their use varies between patients, places and services, or if they are associated with better patient outcomes.

Objectives

To examine variation in the use of community treatment orders and their associations with patient outcomes and health-care costs.

Design

Secondary analysis using multilevel statistical modelling.

Setting

England, including 61 NHS mental health provider trusts.

Participants

A total of 69,832 patients eligible to be subject to a community treatment order.

Main outcome measures

Use of community treatment orders and time subject to community treatment order; re-admission and total time in hospital after the start of a community treatment order; and mortality.

Data sources

The primary data source was the Mental Health Services Data Set. Mental Health Services Data Set data were linked to mortality records and local area deprivation statistics for England.

Results

There was significant variation in community treatment order use between patients, provider trusts and local areas. Most variation arose from substantially different practice in a small number of providers. Community treatment order patients were more likely to be in the ‘severe psychotic’ care cluster grouping, male or black. There was also significant variation between service providers and local areas in the time patients remained on community treatment orders. Although slightly more community treatment order patients were re-admitted than non-community treatment order patients during the study period (36.9% vs. 35.6%), there was no significant difference in time to first re-admission (around 32 months on average for both). There was some evidence that the rate of re-admission differed between community treatment order and non-community treatment order patients according to care cluster grouping. Community treatment order patients spent 7.5 days longer, on average, in admission than non-community treatment order patients over the study period. This difference remained when other patient and local area characteristics were taken into account. There was no evidence of significant variation between service providers in the effect of community treatment order on total time in admission. Community treatment order patients were less likely to die than non-community treatment order patients, after taking account of other patient and local area characteristics (odds ratio 0.69, 95% credible interval 0.60 to 0.81).

Limitations

Confounding by indication and potential bias arising from missing data within the Mental Health Services Data Set. Data quality issues precluded inclusion of patients who were subject to community treatment orders more than once.

Conclusions

Community treatment order use varied between patients, provider trusts and local areas. Community treatment order use was not associated with shorter time to re-admission or reduced time in hospital to a statistically significant degree. We found no evidence that the effectiveness of community treatment orders varied to a significant degree between provider trusts, nor that community treatment orders were associated with reduced mental health treatment costs. Our findings support the view that community treatment orders in England are not effective in reducing future admissions or time spent in hospital. We provide preliminary evidence of an association between community treatment order use and reduced rate of death.

Future work

These findings need to be replicated among patients who are subject to community treatment order more than once. The association between community treatment order use and reduced mortality requires further investigation.

Study registration

The study was approved by the University of Warwick’s Biomedical and Scientific Research Ethics Committee (REGO-2015-1623).

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Smoking and Religion: Untangling Associations Using English Survey Data

While factors affecting smoking are well documented, the role of religion has received little attention. This national study aims to assess the extent to which religious affiliation is associated with current-smoking and ever-smoking, controlling for age, sex, ethnicity and socio-economic status. Variations between adult and youth populations are examined using secondary analysis of individual-level data from 5 years of the Health Survey for England for adult (aged >20, n = 39,837) and youth (aged 16-20, n = 2355) samples. Crude prevalence statistics are contrasted with binary logistic models for current-smoking and ever-smoking in the adult and youth samples. Analyses suggest that Muslims smoke substantially less than Christians. Highest levels of smoking characterise people not professing any religion. Associations between smoking and the Muslim religion attenuate to statistical insignificance in the face of ethnic and socio-economic factors. An association between smoking and the absence of a religious affiliation is sustained. An understanding of the association between smoking and religion is essential to the development of tobacco control programmes.

Which urban land covers/uses are associated with residents' mortality? A cross-sectional, ecological, pan-European study of 233 cities

​OBJECTIVES: The study aim was to determine whether the range and distribution of all, and proportions of specific, land covers/uses within European cities are associated with city-specific mortality rates. ​SETTING: 233 European cities within 24 countries. ​PARTICIPANTS: Aggregated city-level all-cause and age-group standardised mortality ratio for males and females separately and Western or Eastern European Region. ​RESULTS: The proportion of specific land covers/uses within a city was related to mortality, displaying differences by macroregion and sex. The land covers/uses associated with lower standardised mortality ratio (SMR) for both Western and Eastern European cities were those characterised by 'natural' green space, such as forests and semi-natural areas (Western Female coefficient: -18.3, 95% CI -29.8 to -6.9). Dense housing was related to a higher SMR, most prominently in Western European cities (Western Female coefficient: 17.4, 95% CI 9.6 to 25.2). ​CONCLUSIONS: There is pressure to build on urban natural spaces, both for economic gain and because compact cities are regarded as more sustainable, yet here we offer evidence that doing so may detract from residents' health. Our study suggests that urban planners and developers need to regard retaining more wild and unstructured green space as important for healthy city systems.

Differential pathways into smoking among sexual orientation and social class groups in England: A structural equation model

PURPOSE

Previous research has shown that lesbian, gay and bisexual (LGB) populations smoke more than their heterosexual counterparts. Little is known about the pathways into smoking among LGB populations in England relative to the lower social class populations that are the focus of the current Tobacco Control Plan (TCP).

METHODS

Using the 2013/2014 waves of the Health Survey for England (HSE), we created a structural equation model to analyze pathways and interactions between sexual orientation, social class, and the number of cigarettes smoked daily. The path analysis assessed whether three intervening factors-age of initiation, mental wellbeing score, and exposure to smoke-are implicated similarly in smoking among LGB and lower social class populations, and whether interaction between sexual orientation and class is further associated with smoking.

RESULTS

Bivariate analysis showed that LGB-identified individuals and individuals in lower occupational classes smoke more cigarettes daily, respectively, than heterosexual individuals and those in professional/managerial-class populations. Path analysis showed that the number of cigarettes smoked daily was mediated by age of initiation, mental wellbeing score and weekly exposure to smoke among routine and manual workers; by mental wellbeing score and exposure to smoke among intermediate class workers, and by mental wellbeing score in the LGB population. Interactions between sexual orientation and social class were not significant.

CONCLUSIONS

The differential nature of pathways into smoking for lower social classes and LGB populations in England suggests the need for tailored prevention and cessation efforts, with programming for LGB populations focused on the distinct stressors they face.

Examination of how food environment and psychological factors interact in their relationship with dietary behaviours: test of a cross-sectional model

BACKGROUND

To improve population diet environmental strategies have been hailed the panacea because they require little agency or investment of personal resources; this contrasts with conventional strategies that rely on individuals to engage high levels of agency and make deliberate choices. There is an immediate need to improve understanding of the synergy between the psychological and environmental determinants of diet in order to optimise allocation of precious public health resources. This study examined the synergistic and relative association between a number of food environment and psychological factors and the dietary behaviours of a population sample of women with young children.

METHODS

Women in Hampshire were recruited from children's centres and asked about their demographic characteristics, psychological resources, dietary behaviours (food frequency questionnaire) and perceptions of healthy food access and affordability. Three local food environment factors were objectively assessed: i) spatial access to food outlets using activity spaces; ii) healthfulness of the supermarket where women did their main food shop, (based on nine in-store factors including price, placement and promotion on seven healthy and five less healthy foods); iii) nutrition environment of children's centres visited frequently by the women, assessed via staff-administered questionnaire. A theoretical model linking environmental factors to dietary behaviours, both directly and indirectly through three factors representing individual agency (psychological resources, perceived food affordability, perceived food accessibility), was tested using Structural Equation Modelling.

RESULTS

Complete data were available for 753 women. The environment of women's main supermarket was indirectly related to their dietary behaviours through psychological resources and perceived food affordability. Shopping at supermarkets classified as having a healthier in-store environment was associated with having greater psychological resources associated with healthy eating (standardised regression weight β = 0.14SD, p = 0.03) and fewer food affordability concerns (β = - 0.14SD, p = 0.01), which in turn related to healthier dietary behaviours (β = 0.55SD, < 0.001 and β = - 0.15, p = 0.01 respectively). The three food environment factors were not directly associated with dietary behaviour (p > 0.3). The overall model fit was good (CFI = 0.91, RMSEA = 0.05 [0.05, 0.06]).

CONCLUSIONS

This pathway analysis identified three focal points for intervention and suggests that high-agency interventions targeting individual psychological resources when combined with low-agency supermarket environment interventions may confer greater benefits on dietary behaviours than either intervention alone.

Evaluating the effects of community treatment orders (CTOs) in England using the Mental Health Services Dataset (MHSDS): protocol for a national, population-based study

INTRODUCTION

Supervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data.

METHODS AND ANALYSIS

Four years of data from the Mental Health Services Dataset (MHSDS) will be analysed using multilevel models. Models based on all patients eligible for CTOs will be used to explore variation in their use. A subset of CTO-eligible patients comprising a treatment group (CTO patients) and a matched control group (non-CTO patients) will be used to examine variation in the association between CTO use and study outcomes. Primary outcome will be total time in hospital. Secondary outcomes will include time to first readmission and mortality. Outputs from these models will be used to populate predictive models of healthcare resource use.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the National Health Service Data Access and Advisory Group and Warwick University. To ensure patient confidentiality and to meet data governance requirements, analyses will be carried out in a secure microdata laboratory using de-identified data. Study findings will be disseminated through academic channels and shared with mental health policy-makers and other stakeholders.

The tobacco endgame: The neglected role of place and environment

An increasing number of countries across the world are planning for the eradication of the tobacco epidemic. The actions necessary to realise this ambition have been termed the tobacco endgame. The focus of this paper is on the intersection between the tobacco endgame with place, a neglected theme in recent academic and policy debates. We begin with an overview of the key themes in the literature on endgame strategies before detailing the international landscape of engame initiatives, paying particular attention to the opportunities and challenges of endgame strategies in low and middle income countries. Finally, we critically assess the current endgame debates and suggest a novel agenda for integrating geographical perspectives into research on the endgame that provides enhanced understanding of the challenges associated with this important global health vision.

Developing and Applying Geographical Synthetic Estimates of Health Literacy in GP Clinical Systems

Background: Low health literacy is associated with poorer health. Research has shown that predictive models of health literacy can be developed; however, key variables may be missing from systems where predictive models might be applied, such as health service data. This paper describes an approach to developing predictive health literacy models using variables common to both "source" health literacy data and "target" systems such as health services. Methods: A multilevel synthetic estimation was undertaken on a national (England) dataset containing health literacy, socio-demographic data and geographical (Lower Super Output Area: LSOA) indicators. Predictive models, using variables commonly present in health service data, were produced. An algorithm was written to pilot the calculations in a Family Physician Clinical System in one inner-city area. The minimum data required were age, sex and ethnicity; other missing data were imputed using model values. Results: There are 32,845 LSOAs in England, with a population aged 16 to 65 years of 34,329,091. The mean proportion of the national population below the health literacy threshold in LSOAs was 61.87% (SD 12.26). The algorithm was run on the 275,706 adult working-age people in Lambeth, South London. The algorithm could be calculated for 228,610 people (82.92%). When compared with people for whom there were sufficient data to calculate the risk score, people with insufficient data were more likely to be older, male, and living in a deprived area, although the strength of these associations was weak. Conclusions: Logistic regression using key socio-demographic data and area of residence can produce predictive models to calculate individual- and area-level risk of low health literacy, but requires high levels of ethnicity recording. While the models produced will be specific to the settings in which they are developed, it is likely that the method can be applied wherever relevant health literacy data are available. Further work is required to assess the feasibility, accuracy and acceptability of the method. If feasible, accurate and acceptable, this method could identify people requiring additional resources and support in areas such as medical practice.

A realist approach to the evaluation of complex mental health interventions

Conventional approaches to evidence that prioritise randomised controlled trials appear increasingly inadequate for the evaluation of complex mental health interventions. By focusing on causal mechanisms and understanding the complex interactions between interventions, patients and contexts, realist approaches offer a productive alternative. Although the approaches might be combined, substantial barriers remain.Declaration of interestAll authors had financial support from the National Institute for Health Research Health Services and Delivery Research Programme while completing this work. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the National Health Service, the National Institute for Health Research, the Medical Research Council, Central Commissioning Facility, National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, the Health Services and Delivery Research Programme or the Department of Health. S.P.S. is part funded by Collaboration for Leadership in Applied Health Research and Care West Midlands. K.B. is editor of the British Journal of Psychiatry.

The utility of geodemographic indicators in small area estimates of limiting long-term illness

Small area health data are not always available on a consistent and robust routine basis across nations, necessitating the employment of small area estimation methods to generate local-scale data or the use of proxy measures. Geodemographic indicators are widely marketed as a potential proxy for many health indicators. This paper tests the extent to which the inclusion of geodemographic indicators in small area estimation methodology can enhance small area estimates of limiting long-term illness (LLTI). The paper contributes to international debates on small area estimation methodologies in health research and the relevance of geodemographic indicators to the identification of health care needs. We employ a multilevel methodology to estimate small area LLTI prevalence in England, Scotland and Wales. The estimates were created with a standard geographically-based model and with a cross-classified model of individuals nested separately in both spatial groupings and non-spatial geodemographic clusters. LLTI prevalence was estimated as a function of age, sex and deprivation. Estimates from the cross-classified model additionally incorporated residuals relating to the geodemographic classification. Both sets of estimates were compared against direct estimates from the 2011 Census. Geodemographic clusters remain relevant to understanding LLTI even after controlling for age, sex and deprivation. Incorporating a geodemographic indicator significantly improves concordance between the small area estimates and the Census. Small area estimates are however consistently below the equivalent Census measures, with the LLTI prevalence in urban areas characterised as 'blue collar' and 'struggling families' being markedly lower. We conclude that the inclusion of a geodemographic indicator in small area estimation can improve estimate quality and enhance understanding of health inequalities. We recommend the inclusion of geodemographic indicators in public releases of survey data to facilitate better small area estimation but caution against assumptions that geodemographic indicators can, on their own, provide a proxy measure of health status.

Place and preference effects on the association between mental health and internal migration within Great Britain

Individuals with mental health needs are more likely to migrate than the general population, but the effects of migration preference and place of residence are often overlooked. These issues are addressed through the application of a novel origin and destination multilevel model to survey data. In comparison to those with good mental health, individuals with poor mental health are more likely to make undesired moves and this is moderated, but not explained by place of residence. Implications for understanding the mental health and migration relationship, and its impact on service provision are then proposed.

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature

There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.

Integrating national surveys to estimate small area variations in poor health and limiting long-term illness in Great Britain

OBJECTIVES

This study aims to address, for the first time, the challenges of constructing small area estimates of health status using linked national surveys. The study also seeks to assess the concordance of these small area estimates with data from national censuses.

SETTING

Population level health status in England, Scotland and Wales.

PARTICIPANTS

A linked integrated dataset of 23 374 survey respondents (16+ years) from the 2011 waves of the Health Survey for England (n=8603), the Scottish Health Survey (n=7537) and the Welsh Health Survey (n=7234).

PRIMARY AND SECONDARY OUTCOME MEASURES

Population prevalence of poorer self-rated health and limiting long-term illness. A multilevel small area estimation modelling approach was used to estimate prevalence of these outcomes for middle super output areas in England and Wales and intermediate zones in Scotland. The estimates were then compared with matched measures from the contemporaneous 2011 UK Census.

RESULTS

There was a strong positive association between the small area estimates and matched census measures for all three countries for both poorer self-rated health (r=0.828, 95% CI 0.821 to 0.834) and limiting long-term illness (r=0.831, 95% CI 0.824 to 0.837), although systematic differences were evident, and small area estimation tended to indicate higher prevalences than census data.

CONCLUSIONS

Despite strong concordance, variations in the small area prevalences of poorer self-rated health and limiting long-term illness evident in census data cannot be replicated perfectly using small area estimation with linked national surveys. This reflects a lack of harmonisation between surveys over question wording and design. The nature of small area estimates as 'expected values' also needs to be better understood.

The relationship between dietary quality and the local food environment differs according to level of educational attainment: A cross-sectional study

There is evidence that food outlet access differs according to level of neighbourhood deprivation but little is known about how individual circumstances affect associations between food outlet access and diet. This study explored the relationship between dietary quality and a measure of overall food environment, representing the balance between healthy and unhealthy food outlet access in individualised activity spaces. Furthermore, this study is the first to assess effect modification of level of educational attainment on this relationship. A total of 839 mothers with young children from Hampshire, United Kingdom (UK) completed a cross-sectional survey including a 20-item food frequency questionnaire to measure diet and questions about demographic characteristics and frequently visited locations including home, children’s centre, general practitioner, work, main food shop and physical activity location. Dietary information was used to calculate a standardised dietary quality score for each mother. Individualised activity spaces were produced by creating a 1000m buffer around frequently visited locations using ArcGIS. Cross-sectional observational food outlet data were overlaid onto activity spaces to derive an overall food environment score for each mother. These scores represented the balance between healthy and unhealthy food outlets using weightings to characterise the proportion of healthy or unhealthy foods sold in each outlet type. Food outlet access was dominated by the presence of unhealthy food outlets; only 1% of mothers were exposed to a healthy overall food environment in their daily activities. Level of educational attainment moderated the relationship between overall food environment and diet (mid vs low, p = 0.06; high vs low, p = 0.04). Adjusted stratified linear regression analyses showed poorer food environments were associated with better dietary quality among mothers with degrees (β = -0.02; 95%CI: -0.03, -0.001) and a tendency toward poorer dietary quality among mothers with low educational attainment, however this relationship was not statistically significant (β = 0.01; 95%CI: -0.01, 0.02). This study showed that unhealthy food outlets, like takeaways and convenience stores, dominated mothers’ food outlet access, and provides some empirical evidence to support the concept that individual characteristics, particularly educational attainment, are protective against exposure to unhealthy food environments. Improvements to the imbalance of healthy and unhealthy food outlets through planning restrictions could be important to reduce dietary inequalities.

What is the association between healthy weight in 4-5-year-old children and spatial access to purposefully constructed play areas?

BACKGROUND

Childhood obesity is a global issue. Understanding associated factors is essential in designing interventions to reduce its prevalence. There are knowledge gaps concerning the leptogenic potential of play areas for very young children and particularly whether there is an association between levels of childhood obesity and play area quality.

METHODS

A cross-sectional observational study was conducted to investigate whether spatial access to play areas had an association with healthy weight status of 4-5-year-old children. Data from the English National Childhood Measurement Programme 2012/13 was used to measure healthy weight status and a geographic information system was used to calculate (a) the number of purposefully constructed play areas within 1km (density), and (b) the distance to nearest play area (proximity), from child's residential postcode. A play area quality score was included in predictive models. Multilevel modelling was used to adjust for the clustering of observations by school. Adjustment was also made for the effects of gender and deprivation.

RESULTS

77% of children had a healthy weight status (≥2nd and <85th centile). In a fully adjusted multilevel model there was no statistically significant association between healthy weight status and density or proximity measures, with or without inclusion of a play area quality score, or when accounting for the effects of gender and deprivation.

CONCLUSIONS

Among 4-5-year-old children attending school, there was no association between healthy weight status and spatial access to play areas. Reasons may include under-utilisation of play areas by reception age children, their minimal leptogenic influence or non-spatial influences affecting play area choice.

Multi-scalar influences on mortality change over time in 274 European cities

Understanding determinants of urban health is of growing importance. Factors at multiple scales intertwine to influence health in cities but, with the growing autonomy of some cities from their countries, city population health may be becoming more a matter for city-level rather than national-level policy and action. We assess the importance of city, country, and macroregional (Western and East-Central Europe) scales to mortality change over time for 274 cities (population 80 million) from 27 European countries. We then investigate whether mortality changes over time are related to changes in city-level affluence. Using Urban Audit data, all-age all-cause standardised mortality ratios (SMRs) for males and females were calculated at three time points (wave one 1999-2002, wave two 2003-2006, and wave three 2007-2009) for each city. Multilevel regression was used to model the SMRs as a function of survey wave and city region gross domestic product (GDP) per 1000 capita. SMRs declined over time and the substantial East-West gap narrowed slightly. Variation at macroregion and country scales characterised SMRs for women in Western and East-Central European cities, and SMRs for men in East-Central European cities. Between-city variation was evident for male SMRs in Western Europe. Changes in city-region GDP per capita were not associated with changes in mortality over the study period. Our results show how geographical scales differentially impact urban mortality. We conclude that changes in urban health should be seen in both city and wider national and macroregional contexts.

Towards a General Explanation for the Survival of the Private Asylum

Taken together, the ascendancy of community care and the dominant role of the state as a funder of services have meant that private sector residential care for people with mental health problems is now a rarity in most countries. Yet private asylums have persisted in some places. The authors propose an analytical framework for understanding such ‘institutional survivals’. This framework problematises the public—private and community—asylum boundaries that have hitherto been taken for granted. The framework is applied to case studies in Canada and New Zealand. Survival of these institutions is found to be centrally associated with accommodations with legislative environments, proactive innovation, and the availability of markets.

The spatial structure of chronic morbidity: evidence from UK census returns

Background

Disease prevalence models have been widely used to estimate health, lifestyle and disability characteristics for small geographical units when other data are not available. Yet, knowledge is often lacking about how to make informed decisions around the specification of such models, especially regarding spatial assumptions placed on their covariance structure. This paper is concerned with understanding processes of spatial dependency in unexplained variation in chronic morbidity.

Methods

2011 UK census data on limiting long-term illness (LLTI) is used to look at the spatial structure in chronic morbidity across England and Wales. The variance and spatial clustering of the odds of LLTI across local authority districts (LADs) and middle layer super output areas are measured across 40 demographic cross-classifications. A series of adjacency matrices based on distance, contiguity and migration flows are tested to examine the spatial structure in LLTI. Odds are then modelled using a logistic mixed model to examine the association with district-level covariates and their predictive power.

Results

The odds of chronic illness are more dispersed than local age characteristics, mortality, hospitalisation rates and chance alone would suggest. Of all adjacency matrices, the three-nearest neighbour method is identified as the best fitting. Migration flows can also be used to construct spatial weights matrices which uncover non-negligible autocorrelation. Once the most important characteristics observable at the LAD-level are taken into account, substantial spatial autocorrelation remains which can be modelled explicitly to improve disease prevalence predictions.

Conclusions

Systematic investigation of spatial structures and dependency is important to develop model-based estimation tools in chronic disease mapping. Spatial structures reflecting migration interactions are easy to develop and capture autocorrelation in LLTI. Patterns of spatial dependency in the geographical distribution of LLTI are not comparable across ethnic groups. Ethnic stratification of local health information is needed and there is potential to further address complexity in prevalence models by improving access to disaggregated data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12942-016-0057-5) contains supplementary material, which is available to authorized users.

Education and the Relationship Between Supermarket Environment and Diet

INTRODUCTION

Supermarkets are a major source of food for many families. Knowledge of how educational attainment affects the relationship between in-store environments of supermarkets and diet is needed. This study examined the relationship between maternal dietary quality and overall in-store supermarket environment, and assessed the effect modification of educational attainment.

METHODS

Dietary quality z-scores were calculated for 829 mothers with young children using cross-sectional data collected in 2010-2011 from a 20-item food frequency questionnaire. Information about nine in-store factors (variety, price, quality, promotion, shelf placement, store placement, nutrition information, healthier alternatives, and single fruit sale) on 12 foods known to discriminate between better and poorer dietary quality were collected to create a standardized "healthfulness" z-score for each supermarket where mothers shopped.

RESULTS

Multilevel unadjusted linear regression analysis completed in 2014-2015 showed that shopping at more-healthful supermarkets was associated with better dietary quality (β=0.39 SD/SD, p=0.01, 95% CI=0.10, 0.68). However, the relationship differed according to educational attainment (interaction, p=0.006). Among mothers who left school at age 16 years, those who shopped at less healthful supermarkets had poorer dietary quality (β=0.31 SD/SD, 95% CI=0.07, 0.55). Among mothers with degrees, those who shopped at less healthful supermarkets had better dietary quality (β=-0.59 SD/SD, 95% CI=-1.19, 0.00).

CONCLUSIONS

Mothers with low educational attainment show greater susceptibility to less healthful in-store environments than mothers with higher educational attainment who may be protected by greater psychological and financial resources. Policy initiatives to improve supermarket environments may be necessary to address dietary inequalities.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Using geocoded survey data to improve the accuracy of multilevel small area synthetic estimates

This paper examines the secondary data requirements for multilevel small area synthetic estimation (ML-SASE). This research method uses secondary survey data sets as source data for statistical models. The parameters of these models are used to generate data for small areas. The paper assesses the impact of knowing the geographical location of survey respondents on the accuracy of estimates, moving beyond debating the generic merits of geocoded social survey datasets to examine quantitatively the hypothesis that knowing the approximate location of respondents can improve the accuracy of the resultant estimates. Four sets of synthetic estimates are generated to predict expected levels of limiting long term illnesses using different levels of knowledge about respondent location. The estimates were compared to comprehensive census data on limiting long term illness (LLTI). Estimates based on fully geocoded data were more accurate than estimates based on data that did not include geocodes.

Small area synthetic estimates of smoking prevalence during pregnancy in England

Background

Complete and accurate data on maternal smoking prevalence during pregnancy are not available at a local geographical scale in England. We employ a synthetic estimation approach to predict the expected prevalence of smoking during pregnancy and smoking at delivery by Primary Care Trust (PCT).

Methods

Multilevel logistic regression models were used with data from the 2010 Infant Feeding Survey and 2011 Census to predict the probability of mothers (a) smoking at any point during pregnancy and (b) smoking at delivery, according to age, deprivation, and the ethnic profile of the home area. These probabilities were applied to demographic information on mothers giving birth from 2010/11 Hospital Episode Statistics data to produce expected counts, and prevalence figures, of smokers by PCT, with Bayesian 95 % credible intervals. The expected prevalence of smoking at delivery by PCT was compared with midwife-collected Smoking at the Time of Delivery (SATOD) data using a Bland-Altman plot.

Results

The expected prevalence of smoking during pregnancy by PCT ranged from 8.1 % (95 % CI 5.6–1.0) to 31.6 % (27.5–34.8). The expected prevalence of smoking at delivery ranged from 2.5 % (1.4–4.0) to 17.1 % (13.7–20.4). Figures for expected smoking prevalence at delivery showed some agreement with SATOD, though SATOD data were generally higher than the synthetic estimates (mean difference 2.99 %).

Conclusions

It is possible to derive good estimates of expected smoking prevalence during pregnancy for small areas, potentially at much lower cost than conducting large surveys. Such data may be useful to help plan and commission smoking cessation services and monitor their effectiveness.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-015-0067-8) contains supplementary material, which is available to authorized users.

Exploration of chronic kidney disease prevalence estimates using new measures of kidney function in the health survey for England

BACKGROUND

Chronic kidney disease (CKD) diagnosis relies on glomerular filtration rate (eGFR) estimation, traditionally using the creatinine-based Modification of Diet in Renal Disease (MDRD) equation. The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation performs better in estimating eGFR and predicting mortality and CKD progression risk. Cystatin C is an alternative glomerular filtration marker less influenced by muscle mass. CKD risk stratification is improved by combining creatinine eGFR with cystatin C and urinary albumin to creatinine ratio (uACR). We aimed to identify the impact of introducing CKDEPI and cystatin C on the estimated prevalence and risk stratification of CKD in England and to describe prevalence and associations of cystatin C.

METHODS AND FINDINGS

Cross sectional study of 5799 people in the nationally representative 2009 and 2010 Health Surveys for England.

PRIMARY OUTCOME MEASURES

prevalence of MDRD, CKDEPI and cystatin C-defined eGFR<60 ml/min/1.73 m(2); prevalence of CKD biomarker combinations (creatinine, cystatin C, uACR). Using CKDEPI instead of MDRD reduced the prevalence of eGFR<60 ml/min/1.73 m(2) from 6.0% (95% CI 5.4-6.6%) to 5.2% (4.7-5.8%) equivalent to around 340,000 fewer individuals in England. Those reclassified as not having CKD evidenced a lower risk profile. Prevalence of cystatin C eGFR<60 ml/min/1.73 m(2) was 7.7% and independently associated with age, lack of qualifications, being an ex-smoker, BMI, hypertension, and albuminuria. Measuring cystatin C in the 3.9% people with CKDEPI-defined eGFR<60 ml/min/1.73 m(2) without albuminuria (CKD Category G3a A1) reclassified about a third into a lower risk group with one of three biomarkers and two thirds into a group with two of three. Measuring cystatin C in the 6.7% people with CKDEPI eGFR >60 ml/min/1.73 m(2) with albuminuria (CKD Category G1-2) reclassified almost a tenth into a higher risk group.

LIMITATIONS

Cross sectional study, single eGFR measure, no measured ('true') GFR.

CONCLUSIONS

Introducing the CKDEPI equation and targeted cystatin C measurement reduces estimated CKD prevalence and improves risk stratification.

Examining the significance of urban-rural context in tobacco quitline use: does rurality matter?

OBJECTIVES

The purpose of this study was to examine the importance of urban-rural context as a determinant of call rates to smoking cessation lines.

METHODS

This study used individual level New Zealand Quitline call data from 2005 to 2009, and 2006 New Zealand Census data on smoking to calculate Quitline call rates for smokers. Negative binomial regression examined the relationship between call rates and a sevenfold urban-rural classification, controlling for age, sex, ethnicity and deprivation.

RESULTS

We found a significant urban-rural gradient in the rate of smokers calling Quitline. Rates were highest among smokers in main-urban areas [0.09 (95 % confidence interval (CI) = 0.089, 0.091)] decreasing with successive urban-rural classifications to the lowest rate in rural/remote areas [0.036 (95 % CI = 0.03, 0.04)]. This association was not confounded by age, sex, ethnicity or deprivation.

CONCLUSIONS

Smokers in rural areas are less likely to use the New Zealand Quitline, even after controlling for confounding factors. This suggests that the national quitline is less effective in reaching rural smokers and more attention to the promotion of smoking cessation in rural communities is needed.

Change in prevalence of chronic kidney disease in England over time: comparison of nationally representative cross-sectional surveys from 2003 to 2010

OBJECTIVES

To determine whether the prevalence of chronic kidney disease (CKD) in England has changed over time.

DESIGN

Cross-sectional analysis of nationally representative Health Survey for England (HSE) random samples.

SETTING

England 2003 and 2009/2010.

SURVEY PARTICIPANTS

13,896 adults aged 16+ participating in HSE, adjusted for sampling and non-response, 2009/2010 surveys combined.

MAIN OUTCOME MEASURE

Change in prevalence of estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m2 (as proxy for stage 3-5 CKD), from 2003 to 2009/2010 based on a single serum creatinine measure using an isotope dilution mass spectrometry traceable enzymatic assay in a single laboratory; eGFR derived using Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) eGFR formulae.

ANALYSIS

Multivariate logistic regression modelling to adjust time changes for sociodemographic and clinical factors (body mass index, hypertension, diabetes, lipids). A correction factor was applied to the 2003 HSE serum creatinine to account for a storage effect.

RESULTS

National prevalence of low eGFR (<60) decreased within each age and gender group for both formulae except in men aged 65-74. Prevalence of obesity and diabetes increased in this period, while there was a decrease in hypertension. Adjustment for demographic and clinical factors led to a significant decrease in CKD between the surveyed periods. The fully adjusted OR for eGFR<60 mL/min/1.73 m2 was 0.75 (0.61 to 0.92) comparing 2009/2010 with 2003 using the MDRD equation, and was similar using the CKDEPI equation 0.73 (0.57 to 0.93).

CONCLUSIONS

The prevalence of a low eGFR indicative of CKD in England appeared to decrease over this 7-year period, despite the rising prevalence of obesity and diabetes, two key causes of CKD. Hypertension prevalence declined and blood pressure control improved but this did not appear to explain the fall. Periodic assessment of eGFR and albuminuria in future HSEs is needed to evaluate trends in CKD.

Measuring the healthfulness of food retail stores: variations by store type and neighbourhood deprivation

Background

The consumer nutrition environment has been conceptualised as in-store environmental factors that influence food shopping habits. More healthful in-store environments could be characterised as those which promote healthful food choices such as selling good quality healthy foods or placing them in prominent locations to prompt purchasing. Research measuring the full-range of in-store environmental factors concurrently is limited.

Purpose

To develop a summary score of ‘healthfulness’ composed of nine in-store factors that influence food shopping behaviour, and to assess this score by store type and neighbourhood deprivation.

Methods

A cross-sectional survey of 601 retail food stores, including supermarkets, grocery stores and convenience stores, was completed in Hampshire, United Kingdom between July 2010 and June 2011. The survey measured nine variables (variety, price, quality, promotions, shelf placement, store placement, nutrition information, healthier alternatives and single fruit sale) to assess the healthfulness of retail food stores on seven healthy and five less healthy foods that are markers of diet quality. Four steps were completed to create nine individual variable scores and another three to create an overall score of healthfulness for each store.

Results

Analysis of variance showed strong evidence of a difference in overall healthfulness by store type (p < 0.001). Large and premium supermarkets offered the most healthful shopping environments for consumers. Discount supermarkets, ‘world’, convenience and petrol stores offered less healthful environments to consumers however there was variation across the healthfulness spectrum. No relationship between overall healthfulness and neighbourhood deprivation was observed (p = 0.1).

Conclusions

A new composite measure of nine variables that can influence food choices was developed to provide an overall assessment of the healthfulness of retail food stores. This composite score could be useful in future research to measure the relationship between main food store and quality of diet, and to evaluate the effects of multi-component food environment interventions.

Chronic kidney disease, albuminuria and socioeconomic status in the Health Surveys for England 2009 and 2010

BACKGROUND

Renal replacement therapy rates are inversely related to socioeconomic status (SES) in developed countries. The relationship between chronic kidney disease (CKD) and SES is less clear. This study examined the relationships between SES and CKD and albuminuria in England.

METHODS

Data from the Health Survey for England 2009 and 2010 were combined. The prevalence of CKD 3-5 and albuminuria was calculated, and logistic regression used to determine their association with five individual-level measures and one area-level measure of SES.

RESULTS

The prevalence of CKD 3-5 was 5.2% and albuminuria 8.0%. Age-sex-adjusted CKD 3-5 was associated with lack of qualifications [odds ratio (OR) 2.27 (95% confidence interval 1.40-3.69)], low income [OR 1.50 (1.02-2.21)] and renting tenure [OR 1.36 (1.01-1.84)]. Only tenure remained significant in fully adjusted models suggesting that co-variables were on the causal pathway. Albuminuria remained associated with several SES measures on full adjustment: low income [OR 1.55 (1.14-2.11)], no vehicle [OR 1.38 (1.05-1.81)], renting [OR 1.31 [1.03-1.67)] and most deprived area-level quintile [OR 1.55 (1.07-2.25)].

CONCLUSIONS

CKD 3-5 and albuminuria were associated with low SES using several measures. For albuminuria this was not explained by known measured causal factors.

Dietary inequalities: what is the evidence for the effect of the neighbourhood food environment?

This review summarises the evidence for inequalities in community and consumer nutrition environments from ten previous review articles, and also assesses the evidence for the effect of the community and consumer nutrition environments on dietary intake. There is evidence for inequalities in food access in the US but trends are less apparent in other developed countries. There is a trend for greater access and availability to healthy and less healthy foods relating to better and poorer dietary outcomes respectively. Trends for price show that higher prices of healthy foods are associated with better dietary outcomes. More nuanced measures of the food environment, including multidimensional and individualised approaches, would enhance the state of the evidence and help inform future interventions.

The spatial and temporal development of binge drinking in England 2001-2009: an observational study

Binge drinking has been linked to escalating costs of hospitalisation and to premature mortality, and implicated in a range of acute and chronic health problems as well as crime, violence and other negative aspects of the wider well-being agenda. Variously defined, it can be characterised as brief periods of heavy drinking (across one day or evening) within a longer time-frame of lower consumption or even abstinence (across a week or several weeks). In England the current binge drinking epidemic has become particularly salient in the past decade and has been seen largely in terms of excessive consumption by younger people, particularly women in urban centres. It has also been linked to the liberalisation of licencing laws and the promotion of 24 h club cultures. This paper presents an observational study of the regional development of binge drinking between 2001 and 2009 as evidenced in the Health Survey for England. We innovate by using two different definitions of binge drinking within a multivariate multilevel modelling framework, with a focus on the random effects attributable to the year of study and region. We control for age, sex, ethnicity, marital status and individual socio-economic status, and confounding by neighbourhood deprivation and urbanisation. The paper identifies pronounced regional geographies that persist in the face of controls and vary little over time, and strong spatio-temporal gender differences which reflect the definition of binge drinking.

Variety and quality of healthy foods differ according to neighbourhood deprivation

This study addresses a gap in the food environment literature by investigating spatial differences in the inter relationship of price, variety and quality of food in southern England. We conducted a survey of all grocery stores (n=195) in the city of Southampton, UK, and ranked neighbourhoods according to national quintiles of deprivation. We found no difference in availability or cheapest price across neighbourhoods. However, the poorest neighbourhoods had less variety of healthy products and poorer quality fruit and vegetables than more affluent neighbourhoods. Dietary inequalities may be exacerbated by differences in the variety and quality of healthy foods sold locally; these factors may influence whether or not consumers purchase healthy foods.