Tracking reading skills and reading-related skills in dyslexia before (age 5) and after (ages 10-17) diagnosis

This study had three goals: to examine the stability of deficits in the phonological and lexical routes in dyslexia (group study), to determine the prevalence of dyslexia profiles (multiple-case study), and to identify the prediction of phonemic segmentation and discrimination skills before reading acquisition on future reading level. Among a group of 373 non-readers seen at age 5, 38 students were subsequently diagnosed as either consistent dyslexic readers (18 DYS) or consistent typical readers (20 TR). Their phonological and lexical reading skills were assessed at ages 10 and 17 and their phonemic segmentation and discrimination skills at age 5. In comparison with TR of the same chronological age (CA-TR), individuals with dyslexia demonstrated an impairment of the two reading routes, especially of the phonological reading route. In the comparison with younger TR (age 10) of the same reading level (RL-TR), only a deficit of the phonological route is observed. In the multiple-case study, the comparisons with CA-TR showed a prevalence of mixed profiles and very few dissociated profiles, whereas the comparison with RL-TR resulted mostly in two profiles depending on the measure: a phonological profile when accuracy was used and a delayed profile when speed was used. In addition, the correlations between early phonemic segmentation and discrimination skills (age 5) and later reading skills (age 17) were significant, and in the group of individuals with dyslexia, early phonemic segmentation skills significantly predicted these later reading skills. Phonological reading deficits are persistent and mainly caused by early phonemic impairments.

A population-based cohort study of obesity, ethnicity and COVID-19 mortality in 12.6 million adults in England

Obesity and ethnicity are known risk factors for COVID-19 outcomes, but their combination has not been extensively examined. We investigate the association between body mass index (BMI) and COVID-19 mortality across different ethnic groups using linked national Census, electronic health records and mortality data for adults in England from the start of pandemic (January 2020) to December 2020. There were 30,067 (0.27%), 1,208 (0.29%), 1,831 (0.29%), 845 (0.18%) COVID-19 deaths in white, Black, South Asian and other ethnic minority groups, respectively. Here we show that BMI was more strongly associated with COVID-19 mortality in ethnic minority groups, resulting in an ethnic risk of COVID-19 mortality that was dependant on BMI. The estimated risk of COVID-19 mortality at a BMI of 40 kg/m² in white ethnicities was equivalent to the risk observed at a BMI of 30.1 kg/m², 27.0 kg/m², and 32.2 kg/m² in Black, South Asian and other ethnic minority groups, respectively.

Barriers and facilitators to physical activity in second-generation British Indian women: A qualitative study

Aim

To understand the barriers to and motivations for physical activity among second-generation British Indian women.

Subject

Approximately 50% of British South Asians are UK-born, and this group is increasing as the second-generation also have children. Previous research into the barriers to and facilitators for physical activity has focused on migrant, first-generation populations. Qualitative research is needed to understand a) how we might further reduce the gap in physical activity levels between White British women and British Indian women and b) the different approaches that may be required for different generations.

Methods

Applying a socioecological model to take into account the wider social and physical contexts, we conducted semi-structured interviews with 28 Indian women living in Manchester, England. Interviews with first-generation British Indian women were also included to provide a comparator. Interviews were audio-recorded, transcribed, thematically coded and analysed using a grounded theory approach.

Results

Ways of socialising, concerns over appearance while being physically active, safety concerns and prioritising educational attainment in adolescence were all described as barriers to physical activity in second-generation British Indian women. Facilitators for physical activity included acknowledging the importance of taking time out for oneself; religious beliefs and religious groups promoting activity; being prompted by family illness; positive messages in both the media and while at school, and having local facilities to use.

Conclusions

Barriers to physical activity in second-generation Indian women were very similar to those already reported for White British women. Public health measures aimed at women in the general population may also positively affect second-generation Indian women. First-generation Indian women, second-generation children and Muslim women may respond better to culturally tailored interventions.

Ethnicity and the tumour characteristics of invasive breast cancer in over 116,500 women in England

BACKGROUND

Ethnic minority women are commonly reported to have more aggressive breast cancer than White women, but there is little contemporary national evidence available.

METHODS

We analysed data from the National Cancer Registration and Analysis Service on women diagnosed with invasive breast cancer during 2013-2018. Multivariable logistic regression yielded adjusted odds ratios (and 95% confidence intervals) of less favourable tumour characteristics (high stage, high grade, ER negative, Her2 positive) by ethnicity (black African, black Caribbean, Indian, Pakistani and white) in younger (30-46 years) and older (53-70 years) women.

RESULTS

In 24,022 women aged 30-46 at diagnosis, all ethnic minority groups apart from Indian women had a significantly greater odds of certain less favourable tumour characteristics compared to white women in fully adjusted models. In 92,555 women aged 53-70, all ethnic minorities had a significantly greater adjusted odds of several of the less favourable tumour characteristics. These differences were most marked in black African and black Caribbean women.

CONCLUSIONS

Ethnic minority women are at greater risk of breast cancers with less favourable characteristics, even after allowing for age and other potential confounders. These differences are greater in older than younger women, and in the Black rather than South Asian ethnic groups.

Ethnicity-specific BMI cutoffs for obesity based on type 2 diabetes risk in England: a population-based cohort study

BACKGROUND

National and global recommendations for BMI cutoffs to trigger action to prevent obesity-related complications like type 2 diabetes among non-White populations are questionable. We aimed to prospectively identify ethnicity-specific BMI cutoffs for obesity based on the risk of type 2 diabetes that are risk-equivalent to the BMI cutoff for obesity among White populations (≥30 kg/m2).

METHODS

In this population-based cohort study, we used electronic health records across primary care (Clinical Practice Research Datalink) linked to secondary care records (Hospital Episodes Statistics) from a network of general practitioner practices in England. Eligible participants were aged 18 years or older, without any past or current diagnosis of type 2 diabetes, had a BMI of 15·0-50·0 kg/m2 and complete ethnicity data, were registered with a general practitioner practice in England at any point between Sept 1, 1990, and Dec 1, 2018, and had at least 1 year of follow-up data. Patients with type 2 diabetes were identified by use of a CALIBER phenotyping algorithm. Self-reported ethnicity was collapsed into five main categories. Age-adjusted and sex-adjusted negative binomial regression models, with fractional polynomials for BMI, were fitted with incident type 2 diabetes and ethnicity data.

FINDINGS

1 472 819 people were included in our study, of whom 1 333 816 (90·6%) were White, 75 956 (5·2%) were south Asian, 49 349 (3·4%) were Black, 10 934 (0·7%) were Chinese, and 2764 (0·2%) were Arab. After a median follow-up of 6·5 years (IQR 3·2-11·2), 97 823 (6·6%) of 1 472 819 individuals were diagnosed with type 2 diabetes. For the equivalent age-adjusted and sex-adjusted incidence of type 2 diabetes at a BMI of 30·0 kg/m2 in White populations, the BMI cutoffs were 23·9 kg/m2 (95% CI 23·6-24·0) in south Asian populations, 28·1 kg/m2 (28·0-28·4) in Black populations, 26·9 kg/m2 (26·7-27·2) in Chinese populations, and 26·6 kg/m2 (26·5-27·0) in Arab populations.

INTERPRETATION

Revisions of ethnicity-specific BMI cutoffs are needed to ensure that minority ethnic populations are provided with appropriate clinical surveillance to optimise the prevention, early diagnosis, and timely management of type 2 diabetes.

FUNDING

National Institute for Health Research.

Parents' and guardians' views on the acceptability of a future COVID-19 vaccine: A multi-methods study in England

BACKGROUND

The availability of a COVID-19 vaccine has been heralded as key to controlling the COVID-19 pandemic. COVID-19 vaccination programme success will rely on public willingness to be vaccinated.

METHODS

We used a multi-methods approach - involving an online cross-sectional survey and semi-structured interviews - to investigate parents' and guardians' views on the acceptability of a future COVID-19 vaccine. 1252 parents and guardians (aged 16 + years) who reported living in England with a child aged 18 months or under completed the survey. Nineteen survey participants were interviewed.

FINDINGS

Most survey participants reported they would likely accept a COVID-19 vaccine for themselves (Definitely 55.8%; Unsure but leaning towards yes 34.3%) and their child/children (Definitely 48.2%; Unsure but leaning towards yes 40.9%). Less than 4% of survey participants reported that they would definitely not accept a COVID-19 vaccine. Survey participants were more likely to accept a COVID-19 vaccine for themselves than their child/children. Participants that self-reported as Black, Asian, Chinese, Mixed or Other ethnicity were almost 3 times more likely to reject a COVID-19 vaccine for themselves and their children than White British, White Irish and White Other participants. Survey participants from lower-income households were also more likely to reject a COVID-19 vaccine. In open-text survey responses and interviews, self-protection from COVID-19 was reported as the main reason for vaccine acceptance. Common concerns identified in open-text responses and interviews were around COVID-19 vaccine safety and effectiveness, mostly prompted by the newness and rapid development of the vaccine.

CONCLUSION

Information on how COVID-19 vaccines are developed and tested, including their safety and efficacy, must be communicated clearly to the public. To prevent inequalities in uptake, it is crucial to understand and address factors that may affect COVID-19 vaccine acceptability in ethnic minority and lower-income groups who are disproportionately affected by COVID-19.

Age at diagnosis of cancer in 185delAG BRCA1 mutation carriers of diverse ethnicities: tentative evidence for modifier factors

Germline pathogenic sequence variants (PSVs) in BRCA1 substantially increase risk for developing breast (BC) and ovarian cancer (OvC). Yet, incomplete penetrance suggests that modifier factors affect phenotypic expression of mutant BRCA1 alleles. Analysis of identical BRCA1 PSV carriers of diverse ethnicities may provide further evidence for modifier factors. Female carriers of the 185delAG BRCA1 PSV identified through high-risk clinics in Israel, and Manchester England from 1998-2018 were eligible. Data were retrieved from patients records and confirmed (in Israel) by cross referencing with the Israeli National Cancer Registry. Overall, 2503 female carriers were included: 1715 (71.4%) Ashkenazi Jews (AJ), 201 (8.3%) Iraqi Jews and 383 (15.9%) of mixed ethnicity. In 102 (4.2%) cases ethnicity could not be ascertained. Of Israeli AJ carriers 649 (37.8%), 256 (14.9%) and 62 (3.6%) were diagnosed with BC, OvC or both cancers, respectively. For the Iraqi Jews these frequencies were 76 (37.8%), 43 (21.4%), and 8 (3.98%), respectively. Age at diagnosis of BC in AJ and Iraqi Jews was 46.7 ± 12.3 years and 52.8 ± 12.2 years, respectively (p = 0.001). For OvC age at diagnosis for AJ was 53.5 ± 10.7 years and for Iraqi Jews 50.1 ± 8.8 years (p = 0.0027). No differences in these parameters were noted between English Jews (n = 110) and non-Jews (n = 32). Age at diagnosis of BC and OvC differs between AJ and Iraqi Jews who carry an identical BRCA1 PSV. This finding supports the existence of modifier factors that may be ethnic specific.

Using behavioural insights to increase HIV self-sampling kit returns: a randomized controlled text message trial to improve England's HIV self-sampling service

OBJECTIVES

The aim of the study was to determine whether behaviourally informed short message service (SMS) primer and reminder messages could increase the return rate of HIV self-sampling kits ordered online.

METHODS

The study was a 2 × 2 factorial design randomized control trial. A total of 9585 individuals who ordered a self-sampling kit from www.freetesting.hiv different SMS combinations: 1) standard reminders sent days 3 and 7 after dispatch (control); 2) primer sent 1 day after dispatch plus standard reminders; 3) behavioural insights (BI) reminders (no primer); or 4) primer plus BI reminders. The analysis was restricted to individuals who received all messages (n = 8999). We used logistic regression to investigate independent effects of the primer and BI reminders and their interaction. We explored the impact of sociodemographic characteristics on kit return as a secondary analysis.

RESULTS

Those who received the primer and BI reminders had a return rate 4% higher than that of those who received the standard messages. We found strong evidence of a positive effect of the BI reminders (odds ratio 1.13; 95% confidence interval 1.04-1.23; P = 0.003) but no evidence for an effect of the primer, or for an interaction between the two interventions. Odds of kit return increased with age, with those aged ≥ 65 years being almost 2.5 times more likely to return the kit than those aged 25-34 years. Men who have sex with men were 1.5-4.5 times more likely to return the kit compared with other sexual behaviour and gender identity groups. Non-African black clients were 25% less likely to return the kit compared with other ethnicities.

CONCLUSIONS

Adding BI to reminder messages was successful in improving return rates at no additional cost.

HIV incidence among sexual health clinic attendees in England: First estimates for black African heterosexuals using a biomarker, 2009-2013

Introduction

The HIV epidemic in England is largely concentrated among heterosexuals who are predominately black African and men who have sex with men (MSM). We present for the first time trends in annual HIV incidence for adults attending sexual health clinics, where 80% of all HIV diagnoses are made.

Methods

We identified newly diagnosed incident HIV using a recent infection testing algorithm (RITA) consisting of a biomarker (AxSYM assay, modified to determine antibody avidity), epidemiological and clinical information. We estimated HIV incidence using the WHO RITA formula for cross-sectional studies, with HIV testing data from sexual health clinics as the denominator.

Results

From 2009 to 2013, each year, between 9,700 and 26,000 black African heterosexuals (of between 161,000 and 231,000 heterosexuals overall) were included in analyses. For the same period, annually between 19,000 and 55,000 MSM were included. Estimates of HIV incidence among black Africans increased slightly (although non-significantly) from 0.15% (95% C.I.0.05%-0.26%) in 2009 to 0.19% (95% C.I.0.04%-0.34%) in 2013 and was 4-5-fold higher than among all heterosexuals among which it remained stable between 0.03% (95% C.I.0.02%-0.05%) and 0.05% (95% C.I.0.03%-0.07%) over the period. Among MSM incidence was highest and increased (non-significantly) from 1.24% (95%C.I 0.96–1.52%) to 1.46% (95% C.I 1.23%-1.70%) after a peak of 1.52% (95%C.I 1.30%-1.75%) in 2012.

Conclusion

These are the first nationwide estimates for trends in HIV incidence among black African and heterosexual populations in England which show black Africans, alongside MSM, remain disproportionately at risk of infection. Although people attending sexual health clinics may not be representative of the general population, nearly half of black Africans and MSM had attended in the previous 5 years. Timely and accurate incidence estimates will be critical in monitoring the impact of the reconfiguration of sexual health services in England, and any prevention programmes such as pre-exposure prophylaxis.

Spatial clusters of gonorrhoea in England with particular reference to the outcome of partner notification: 2012 and 2013

BACKGROUND

This study explored spatial-temporal variation in diagnoses of gonorrhoea to identify and quantify endemic areas and clusters in relation to patient characteristics and outcomes of partner notification (PN) across England, UK.

METHODS

Endemic areas and clusters were identified using a two-stage analysis with Kulldorff's scan statistics (SaTScan).

RESULTS

Of 2,571,838 tests, 53,547 diagnoses were gonorrhoea positive (positivity = 2.08%). The proportion of diagnoses in heterosexual males was 1.5 times that in heterosexual females. Among index cases, men who have sex with men (MSM) were 8 times more likely to be diagnosed with gonorrhoea than heterosexual males (p<0.0001). After controlling for age, gender, ethnicity and deprivation rank, 4 endemic areas were identified including 11,047 diagnoses, 86% of which occurred in London. 33 clusters included 17,629 diagnoses (34% of total diagnoses in 2012 and 2013) and spanned 21 locations, some of which were dominated by heterosexually acquired infection, whilst others were MSM focused. Of the 53,547 diagnoses, 14.5% (7,775) were the result of PN. The proportion of patients who attended services as a result of PN varied from 0% to 61% within different age, gender and sexual orientation cohorts. A third of tests resulting from PN were positive for gonorrhoea. 25% of Local Authorities (n = 81, 95% CI: 20.2, 29.5) had a higher than expected proportion for female PN diagnoses as compared to 16% for males (n = 52, 95% CI: 12.0, 19.9).

CONCLUSIONS

The English gonorrhoea epidemic is characterised by spatial-temporal variation. PN success varied between endemic areas and clusters. Greater emphasis should be placed on the role of PN in the control of gonorrhoea to reduce the risk of onward transmission, re-infection, and complications of infection.

Clinical Features, Molecular Heterogeneity, and Prognostic Implications in YARS2-Related Mitochondrial Myopathy

Importance

YARS2 mutations have been associated with a clinical triad of myopathy, lactic acidosis, and sideroblastic anemia in predominantly Middle Eastern populations. However, the identification of new patients expands the clinical and molecular spectrum of mitochondrial disorders.

Objectives

To review the clinical, molecular, and genetic features of YARS2-related mitochondrial disease and to demonstrate a new Scottish founder variant.

Design, Setting, and Participants

An observational case series study was conducted at a national diagnostic center for mitochondrial disease in Newcastle upon Tyne, England, and review of cases published in the literature. Six adults in a well-defined mitochondrial disease cohort and 11 additional cases described in the literature were identified with YARS2 variants between January 1, 2000, and January 31, 2015.

Main Outcome and Measures

The spectrum of clinical features and disease progression in unreported and reported patients with pathogenic YARS2 variants.

Results

Seventeen patients (median [interquartile range] age at onset, 1.5 [9.8] years) with YARS2-related mitochondrial myopathy were identified. Fifteen individuals (88%) exhibited an elevated blood lactate level accompanied by generalized myopathy; only 12 patients (71%) manifested with sideroblastic anemia. Hypertrophic cardiomyopathy (9 [53%]) and respiratory insufficiency (8 [47%]) were also prominent clinical features. Central nervous system involvement was rare. Muscle studies showed global cytochrome-c oxidase deficiency in all patients tested and severe, combined respiratory chain complex activity deficiencies. Microsatellite genotyping demonstrated a common founder effect shared between 3 Scottish patients with a p.Leu392Ser variant. Immunoblotting from fibroblasts and myoblasts of an affected Scottish patient showed normal YARS2 protein levels and mild respiratory chain complex defects. Yeast modeling of novel missense YARS2 variants closely correlated with the severity of clinical phenotypes.

Conclusions and Relevance

The p.Leu392Ser variant is likely a newly identified founder YARS2 mutation. Testing for pathogenic YARS2 variants should be considered in patients presenting with mitochondrial myopathy, characterized by exercise intolerance and muscle weakness even in the absence of sideroblastic anemia irrespective of ethnicity. Regular surveillance and early treatment for cardiomyopathy and respiratory muscle weakness is advocated because early treatment may mitigate the significant morbidity and mortality associated with this genetic disorder.

Impact of maternal antibodies and infant gut microbiota on the immunogenicity of rotavirus vaccines in African, Indian and European infants: protocol for a prospective cohort study

INTRODUCTION

Gastroenteritis is the leading cause of morbidity and mortality among young children living in resource-poor settings, majority of which is attributed to rotavirus. Rotavirus vaccination can therefore have a significant impact on infant mortality. However, rotavirus vaccine efficacy in Sub-Saharan Africa and Southeast Asia is significantly lower than in high-income countries. Maternally derived antibodies, infant gut microbiota and concomitant oral polio vaccination have been proposed as potential reasons for poor vaccine performance in low-income settings. The overall aim of this study is to compare the role of maternally derived antibodies and infant gut microbiota in determining immune response to rotavirus vaccine in high-income and low-income settings, using the same vaccine and a similar study protocol.

METHODS AND ANALYSIS

The study is an observational cohort in three countries-Malawi, India and UK. Mothers will be enrolled in third trimester of pregnancy and followed up, along with infants after delivery, until the infant completes two doses of oral rotavirus vaccine (along with routine immunisation). The levels of prevaccination maternally derived rotavirus-specific antibodies (IgG) will be correlated with infant seroconversion and antibody titres, 4 weeks after the second dose of rotavirus vaccine. Both within-country and between-country comparisons of gut microbiome will be carried out between children who seroconvert and those who do not. The impact of oral polio vaccine coadministration on rotavirus vaccine response will be studied in Indian infants.

ETHICS AND DISSEMINATION

Ethical approvals have been obtained from Integrated Research Application System (IRAS, NHS ethics) in UK, College of Medicine Research and Ethics Committee (COMREC) in Malawi and Institutional Review Board (IRB), Christian Medical College, Vellore in India. Participant recruitment and follow-up is ongoing at all three sites. Analysis of data, followed by publication of the results, is expected in 2018.

Marital Status and the Risk of Suicide: Experience from England and Wales, 1982–1996

This analysis examined suicide rates by age, sex, and marital status in England and Wales for the period 1982–1996. Never married, widowed, and divorced people had higher rates of suicide than those who were married, for both sexes. Among the widowed ages 20–39 years, both sexes had the highest rate, and the rate decreased with age. The suicide rate for divorced people was similar to those who had never married, except for the younger group ages 20–29 years. The male:female ratios for the relative suicide risk for never married, widowed, and divorced to married for both sexes were statistically significantly different for older adults. The decrease in suicide rates observed for the period 1982–1996 in England and Wales was mainly attributable to the reduction of suicide rates among the widowed and divorced.

Prevention of coronary heart disease with statins in UK South Asians and Caucasians

AIMS

To determine the prevalence of subjects eligible for primary and secondary prevention of coronary heart disease (CHD) among the British South Asian population and to compare that with British Caucasians.

METHODS AND RESULTS

We used the Health Survey for England 1998 and 1999 datasets, holding data on 9950 Caucasians and 1938 South Asians. Thresholds for treatment were a total cholesterol >3.5 mmol/l and either a history of cardiovascular disease or elevated estimated CHD risk, adjusted where necessary for ethnic differences. Separate analyses were performed for primary prevention risk thresholds of >15% and >30% over 10 years. The prevalence of previous myocardial infarction, angina, or stroke was higher in South Asian men than in Caucasian but the reverse was seen in women. More than 93% [95% confidence interval (CI) 88-97] of South Asian men and nearly 68% (95% CI 66-71) of Caucasian men older than 55 years have a CHD risk greater than 15% (equivalent to cardiovascular risk of 20%) and a cholesterol above 3.5 mmol/l and would be eligible for treatment with lipid-lowering drugs. The equivalent proportions in women are 55% (95% CI 46-65) and 18% (95% CI 16-20) in South Asians and Caucasians, respectively.

CONCLUSION

Treating this proportion of the population will have a societal impact, the majority of older people becoming patients, and although it may well be cost-effective for individuals, it will require substantial new resources.

Cross-sectional study of ethnic differences in physical fitness among children of South Asian, black African-Caribbean and white European origin: the Child Heart and Health Study in England (CHASE)

OBJECTIVE

Little is known about levels of physical fitness in children from different ethnic groups in the UK. We therefore studied physical fitness in UK children (aged 9-10 years) of South Asian, black African-Caribbean and white European origin.

DESIGN

Cross-sectional study.

SETTING

Primary schools in the UK.

PARTICIPANTS

1625 children (aged 9-10 years) of South Asian, black African-Caribbean and white European origin in the UK studied between 2006 and 2007.

OUTCOME MEASURES

A step test assessed submaximal physical fitness from which estimated VO2 max was derived. Ethnic differences in estimated VO2 max were estimated using multilevel linear regression allowing for clustering at school level and adjusting for age, sex and month as fixed effects.

RESULTS

The study response rate was 63%. In adjusted analyses, boys had higher levels of estimated VO2 max than girls (mean difference 3.06 mL O2/min/kg, 95% CI 2.66 to 3.47, p<0.0001). Levels of estimated VO2 max were lower in South Asians than those in white Europeans (mean difference -0.79 mL O2/min/kg, 95% CI -1.41 to -0.18, p=0.01); levels of estimated VO2 max in black African-Caribbeans were higher than those in white Europeans (mean difference 0.60 mL O2/min/kg, 95% CI 0.02 to 1.17, p=0.04); these patterns were similar in boys and girls. The lower estimated VO2 max in South Asians, compared to white Europeans, was consistent among Indian, Pakistani and Bangladeshi children and was attenuated by 78% after adjustment for objectively measured physical activity (average daily steps).

CONCLUSIONS

South Asian children have lower levels of physical fitness than white Europeans and black African-Caribbeans in the UK. This ethnic difference in physical fitness is at least partly explained by ethnic differences in physical activity.

Online health check for reducing alcohol intake among employees: a feasibility study in six workplaces across England

BACKGROUND

Most hazardous and harmful drinkers are of working age and do not seek help with their drinking. Occupational health services are uniquely placed to universally screen employees across the range of socioeconomic and ethnic groups. The aim was to explore the feasibility and acceptability of offering electronic screening and brief intervention for alcohol misuse in the context of a health check in six different workplace settings.

METHODS AND FINDINGS

Employees were recruited from six workplaces across England, including three local authorities, one university, one hospital and one petro-chemical company. A total of 1,254 (8%) employees completed the health check and received personalised feedback on their alcohol intake, alongside feedback on smoking, fruit and vegetable consumption and physical activity. Most participants were female (65%) and of 'White British' ethnicity (94%), with a mean age of 43 years (SD 11). Participants were mostly in Intermediate occupations (58%), followed by Higher managerial / professional (39%) and Routine and manual occupations (2%). A quarter of participants (25%) were drinking at hazardous levels (33% male, 21% female), which decreased with age. Sixty-four percent (n=797) of participants completed online follow-up at three months. Most participants were supportive of workplaces offering employees an online health check (95%), their preferred format was online (91%) and many were confident of the confidentiality of their responses (60%). Whilst the feedback reminded most participants of things they already knew (75%), some were reportedly motivated to change their behaviour (13%).

CONCLUSIONS

Online health screening and personalised feedback appears feasible and acceptable, but challenges include low participation rates, potentially attracting 'worried well' employees rather than those at greatest health risk, and less acceptance of the approach among older employees and those from ethnic minority backgrounds and routine or manual occupations.

Ethnic variations in five lower gastrointestinal diseases: Scottish health and ethnicity linkage study

OBJECTIVES

Our objective was to augment the limited evidence mainly from local, clinical studies of ethnic differences in gastrointestinal disorders. Our question was: are there ethnic variations in hospitalisation/death for lower gastrointestinal disorders in Scotland?

SETTING

Scotland.

POPULATION

This retrospective-cohort linked 4.65 (of 4.9) million people in the 2001 census of Scotland (providing data on ethnicity, country of birth and indicators of socioeconomic deprivation) to 9 years of National Health Service hospitalisation and death records.

PRIMARY AND SECONDARY OUTCOME MEASURES AND ANALYSIS

For appendicitis, we studied all ages; for irritable bowel syndrome, ulcerative colitis, Crohn's disease and diverticular disease, we included those ≥20 years. Using Poisson regression (robust variance) we calculated, by ethnic group and sex, first-hospitalisation/death age-adjusted rates per 100,000 person-years, and relative risks (RRs) with 95% CIs multiplied by 100, so the White Scottish reference population had an RR=100.

RESULTS

There were ethnic variations; for example, for irritable bowel syndrome, RRs (95% CIs) were comparatively high in Other White British women (128.4 (111.0 to 148.6)), and low in Pakistani women (75.1 (60.6 to 93.1)). For appendicitis, RRs were high in men in Other White British (145.2 (127.8 to 164.9)), and low in most non-White groups, for example, Pakistanis (73.8 (56.9 to 95.6)). For ulcerative colitis, RRs were high in Indian (169.8 (109.7 to 262.7)) and Pakistani (160.8 (104.2 to 248.2)) men. For Crohn's disease, the RR was high in Pakistani men (209.2 (149.6 to 292.6)). For diverticular disease, RRs were high in Irish men (176.0 (156.9 to 197.5)), and any Mixed background women (144.6 (107.4 to 194.8)), and low in most non-White groups, for example, Chinese men (47.1 (31.0 to 71.6) and women (46.0 (30.4 to 69.8)).

CONCLUSIONS

Appendicitis and diverticular disease were comparatively low in most non-White groups, while ulcerative colitis and Crohn's disease were mostly higher in South Asians. Describing and understanding such patterns may help clinical practice and research internationally.

(Im)perishable Pleasure, (In)destructible Desire: Sexual Themes in U.S. and English News Coverage of Male Circumcision and Female Genital Cutting

Under what conditions do sexual pleasure and desire get addressed in news coverage of sexual health issues like female genital cutting (FGC) and male circumcision (MC)? In this study we employed an embodied ethnosexuality approach to analyze sexual themes in 1,902 items published from 1985 to 2009 in 13 U.S. and 8 English newspapers and news magazines. Journalists' discussions of sexual pleasure, desire, control, problems, and practices differed in quantity and quality depending on the practice and nation to which they pertained. News coverage in both nations presented FGC as impeding female sexual pleasure, desire, and activity in ways that reinforce (hetero)sexist understandings of sexuality. The English press depicted MC as diminishing male sexuality, whereas U.S. papers showed it as enhancing male sexuality. These patterns are influenced by, and serve to reinforce, cultural norms of embodiment and ethnosexual boundaries based on gender, race, and nationality. They may, in turn, shape public understandings of FGC and MC as social problems.

Regular breakfast consumption and type 2 diabetes risk markers in 9- to 10-year-old children in the child heart and health study in England (CHASE): a cross-sectional analysis

BACKGROUND

Regular breakfast consumption may protect against type 2 diabetes risk in adults but little is known about its influence on type 2 diabetes risk markers in children. We investigated the associations between breakfast consumption (frequency and content) and risk markers for type 2 diabetes (particularly insulin resistance and glycaemia) and cardiovascular disease in children.

METHODS AND FINDINGS

We conducted a cross-sectional study of 4,116 UK primary school children aged 9-10 years. Participants provided information on breakfast frequency, had measurements of body composition, and gave fasting blood samples for measurements of blood lipids, insulin, glucose, and glycated haemoglobin (HbA1c). A subgroup of 2,004 children also completed a 24-hour dietary recall. Among 4,116 children studied, 3,056 (74%) ate breakfast daily, 450 (11%) most days, 372 (9%) some days, and 238 (6%) not usually. Graded associations between breakfast frequency and risk markers were observed; children who reported not usually having breakfast had higher fasting insulin (percent difference 26.4%, 95% CI 16.6%-37.0%), insulin resistance (percent difference 26.7%, 95% CI 17.0%-37.2%), HbA1c (percent difference 1.2%, 95% CI 0.4%-2.0%), glucose (percent difference 1.0%, 95% CI 0.0%-2.0%), and urate (percent difference 6%, 95% CI 3%-10%) than those who reported having breakfast daily; these differences were little affected by adjustment for adiposity, socioeconomic status, and physical activity levels. When the higher levels of triglyceride, systolic blood pressure, and C-reactive protein for those who usually did not eat breakfast relative to those who ate breakfast daily were adjusted for adiposity, the differences were no longer significant. Children eating a high fibre cereal breakfast had lower insulin resistance than those eating other breakfast types (p for heterogeneity <0.01). Differences in nutrient intakes between breakfast frequency groups did not account for the differences in type 2 diabetes markers.

CONCLUSIONS

Children who ate breakfast daily, particularly a high fibre cereal breakfast, had a more favourable type 2 diabetes risk profile. Trials are needed to quantify the protective effect of breakfast on emerging type 2 diabetes risk. Please see later in the article for the Editors' Summary.

Progression, symptoms and psychosocial concerns among those severely affected by multiple sclerosis: a mixed-methods cross-sectional study of Black Caribbean and White British people

Objective

Multiple sclerosis is now more common among minority ethnic groups in the UK but little is known about their experiences, especially in advanced stages. We examine disease progression, symptoms and psychosocial concerns among Black Caribbean (BC) and White British (WB) people severely affected by MS.

Design

Mixed methods study of 43 BC and 43 WB people with MS (PwMS) with an Expanded Disability Status Scale (EDSS) ≥6 involving data from in clinical records, face-to-face structured interviews and a nested-qualitative component. Progression Index (PI) and Multiple Sclerosis Severity Score (MSSS) were calculated. To control for selection bias, propensity scores were derived for each patient and adjusted for in the comparative statistical analysis; qualitative data were analysed using the framework approach.

Results

Median EDSS for both groups was (6.5; range: 6.0–9.0). Progression Index (PI) and Multiple Sclerosis Severity Score (MSSS) based on neurological assessment of current EDSS scores identified BC PwMS were more likely to have aggressive disease (PI F = 4.04, p = 0.048, MSSS F = 10.30, p<0.001). Patients’ reports of the time required to reach levels of functional decline equivalent to different EDSS levels varied by group; EDSS 4: BC 2.7 years v/s WB 10.2 years (U = 258.50, p = 0.013), EDSS 6∶6.1 years BC v/s WB 12.7 years (U = 535.500, p = 0.011), EDSS 8: BC 8.7 years v/s WB 10.2 years. Both groups reported high symptom burden. BC PwMS were more cognitively impaired than WB PwMS (F = 9.65, p = 0.003). Thematic analysis of qualitative interviews provides correspondence with quantitative findings; more BC than WB PwMS referred to feelings of extreme frustration and unresolved loss/confusion associated with their rapidly advancing disease. The interviews also reveal the centrality, meanings and impact of common MS-related symptoms.

Conclusions

Delays in diagnosis should be avoided and more frequent reviews may be justified by healthcare services. Culturally acceptable interventions to better support people who perceive MS as an assault on identity should be developed to help them achieve normalisation and enhance self-identity.

Strangers in a strange land: coping with imprisonment as a racial or ethnic foreign national inmate

A wide range of scholarship examining the global effects of neo-liberalism draws attention to the precarious position of individuals who are not seen as part of the social body. While immigrants, racial minorities, and common criminals are central to this discourse, relatively little research has examined how the experiences of these individuals may vary based on statuses other than citizenship when they are imprisoned. Our research focuses on the interactions (between prisoners and between prisoners and correctional staff) of a racially diverse group of Dutch foreign national prisoners incarcerated in England. Although all of these prisoners clearly saw themselves as 'outsiders,' visible minorities faced a unique set of challenges relative to their White counterparts. We consider both the practical and theoretical import of these findings.

The road most travelled: the geographic distribution of road traffic injuries in England

BACKGROUND

Both road safety campaigns and epidemiological research into social differences in road traffic injury risk often assume that road traffic injuries occur close to home. While previous work has examined distance from home to site of collision for child pedestrians in local areas, less is known about the geographic distribution of road traffic injuries from other modes. This study explores the distribution of the distance between home residence and collision site (crash distance) by mode of transport, geographic area, and social characteristics in England.

METHODS

Using 10 years of road casualty data collected by the police, we examined the distribution of crash distance by age, sex, injury severity, area deprivation, urban/rural status, year, day of week, and, in London only, ethnic group.

RESULTS

54% of pedestrians, 39% of cyclists, 17% of powered two-wheeler riders and 16% of car occupants were injured within 1 km of home. 82% of pedestrians, 83% of cyclists, 54% of powered two-wheeler and 53% of car occupants were injured within 5 km of home. We found some social and geographic differences in crash distance: for all transport modes injuries tended to occur closer to home in more deprived or urban areas; younger and older pedestrians and cyclists were also injured closer to home. Crash distance appears to have increased over time for pedestrian, cyclist and car occupant injuries, but has decreased over time for powered two-wheeler injuries.

CONCLUSIONS

Injuries from all travel modes tend to occur quite close to home, supporting assumptions made in epidemiological and road safety education literature. However, the trend for increasing crash distance and the social differences identified may have methodological implications for future epidemiological studies on social differences in injury risk.

Childhood cancer incidence in British Indians & Whites in Leicester, 1996-2008

BACKGROUND

South Asians in England have an increased risk of childhood cancer but incidence by their individual ethnicities using self-assigned ethnicity is unknown. Our objective was to compare the incidence of childhood cancer in British Indians and Whites in Leicester, which has virtually complete, self-assigned, ethnicity data and the largest population of Indians in England.

METHODS

We obtained data on all cancer registrations from 1996 to 2008 for Leicester with ethnicity obtained by linkage to the Hospital Episodes Statistics database. Age-standardised incidence rates were calculated for childhood cancers in Indians and Whites as well as rate ratios, adjusted for age.

RESULTS

There were 33 cancers registered among Indian children and 39 among White children. The incidence rate for Indians was greater compared to Whites for all cancers combined (RR 1.82 (95% CI 1.14 to 2.89); p = 0.01), with some evidence of increased risk of leukaemia (RR 2.20 (0.95 to 5.07); p = 0.07), lymphoma (RR 3.96 (0.99 to 15.84); p = 0.04) and central nervous system tumours (RR 2.70 (1.00 to 7.26); p = 0.05). Rates were also higher in British Indian children compared to children in India.

CONCLUSIONS

British Indian children in Leicester had an increased risk of developing cancer compared to White children, largely due to a higher incidence of central nervous system and haematological malignancies.

Factors distinguishing skilled and less skilled deaf readers: evidence from four orthographies

This study aims to enhance understanding of the factors underlying variance in the reading comprehension skills of prelingually deaf individuals. Participants were 213 sixth through tenth graders with prelingual deafness recruited from four orthographic backgrounds (Hebrew, Arabic, English, and German) and allocated to three distinct reading profiles (levels). A sentence comprehension test manipulating the semantic plausibility of sentences and a word processing experiment requiring rapid determination of the semantic relationship between two real words or between a real word and a pseudohomophonic letter string were used to determine the factors distinguishing skilled from less skilled deaf readers. Findings point to deficits in structural (syntactic) knowledge and deficient knowledge structures, rather than differences in phonological processing skills, as making that distinction. Moreover, the acquisition of such knowledge seems to be modified by particularities of the read orthography.

Longitudinal trends in mental health among ethnic groups in Canada

INTRODUCTION

Immigration continues to transform the ethnic composition of the Canadian population. We investigated whether longitudinal trends in mental distress vary between seven cultural and ethnic groups and whether mental distress within the same ethnic group varies by demographic (immigrant status, sex, age, marital status, place and length of residence), socio-economic (education, income), social support and lifestyle factors.

METHOD

The study population consisted of 14 713 respondents 15 years and older from the first six cycles of the National Population Health Survey (NPHS); 20% reported themselves to be immigrant at Cycle 1, in 1994/1995. The logistic regression model was fitted by modifying a multivariate quasi-likelihood approach, and robust variance estimates were obtained by using balanced repeated replication techniques.

RESULTS

Based on the multivariable model and self-reported data, we observed that female respondents were more likely to report moderate/high mental distress than male respondents; younger respondents more than older respondents; single respondents more than those in a relationship; urban-dwellers more than rural-dwellers; less educated respondents more than more educated respondents; current and former smokers more than non-smokers; and those living in a smoking household more than those living in non-smoking households. The relationship between ethnicity and mental distress was modified by immigrant status, sex, social involvement score and education. Confirming other research, we found an inverted U-shaped relationship between length of stay and mental distress: those who had lived in Canada for less than 2 years were less likely to report moderate/high mental distress, while those who had lived in Canada for 2 to 20 years were significantly more likely to report moderate/high mental distress than those who had lived in Canada for more than 20 years.

CONCLUSION

There is a need to develop ethnicity-specific mental health programs targeting those with low education attainment and low social involvement. Policies and programs should also target women, the younger age group (15-24 years) and low-income adequacy groups.

Negotiating user preferences, discrimination, and demand for migrant labour in long-term care

The restructuring of long-term care for older people has been marked both by the role of the market and by the role of migrant labor. This article develops the analysis of these processes at the microlevel of the provision of care. It draws on data collected as part of a cross-national comparative study on the employment of migrant care workers in residential care homes and home care services for older people in England and Ireland. The article examines, first, the ways in which divisions of race, ethnicity, and citizenship shape the preferences of service providers/employers and some service users as regards who provides care. Second, it examines how the institutional context of quasi-markets in long-term care shapes the negotiation of demand for migrant labor, the racialized preferences of individual users, alongside the rights of care workers to non-discrimination. It is argued that market-oriented policies for personalization, as well as for cost containment, raise implications for divisions of race, ethnicity, and citizenship in the provision of long-term care. At the same time, those divisions point to the limits of framing care in terms of the preferences of the individual as opposed to the social relations in which care is embedded.

Belonging and community: understandings of "home" and "friends" among the English poor, 1750-1850

This article is based on unique ‘narratives of the poor’, that is, letters from poor people to their parishes of settlement, petitions to the London Refuge of the Destitute, and letters from mothers to the London Foundling Hospital, with supportive evidence from newspapers. These display fundamental concepts among the English poor, who were often poorly literate, and who comprised the majority of the population. Discussion focuses upon their understandings of ‘home’, ‘belonging’, ‘friends’, and ‘community’. These key concepts are related here to modern discussions, to set important concerns into historical perspective. ‘Friends’, valuably studied by sociologists such as Pahl, had a wide meaning in the past. ‘Home’ meant (alongside abode) one's parish of legal settlement, where one was entitled to poor relief under the settlement/poor laws. This was where one ‘belonged’. Ideas of ‘community’ were held and displayed even at a distance, among frequently migrant poor, who wrote to their parishes showing strong ties of attachment, right, and local obligation. This discussion explores these issues in connection with belonging and identity. It elucidates the meaning and working of poor law settlement, and is also an exploration of popular mentalities and the semi-literate ways in which these were expressed.

Shutt up: bubonic plague and quarantine in early modern England

The outbreak of bubonic plague that struck London and Westminster in 1636 provoked the usual frenzied response to epidemics, including popular flight and government-mandated quarantine. The government asserted that plague control measures were acts of public health for the benefit of all. However, contrary to this government narrative of disease prevention there was a popular account that portrayed quarantine and isolation as personal punishment rather than prudent policy. In examining the 1636 outbreak on the parish as well as the individual level, reasons for this inconsistency between official and unofficial perspectives emerge. Quarantine and its effects were not classless, and its implementation was not always strictly in the name of public health. Government application of quarantine was remarkably effective, but it could never be uncontroversial both because of circumstances and because of misuse. The flight of the wealthiest from London and Westminster left only the more socially vulnerable to be quarantined. Though plague policy was financially sensitive to the poorest, it was costly to the middling sort. Another cause of controversy was the government's use of quarantine as a punishment to control individuals found breaking other laws. Though not widely publicized, popular narratives continually included grievances about the cruelty and inequity of quarantine and the militaristic nature of its implementation. Despite these objections, quarantine remained a staple of the government response to plague outbreaks throughout the seventeenth century.

The coastal metropolitan corn trade in later seventeenth-century England

Exploiting hitherto unexamined London port book data, this article shows that during the last quarter of the seventeenth century the coastal metropolitan corn import trade was twice the size that historians relying on the work of Gras have assumed it to have been. More significantly, it demonstrates that Gras's failure to examine the capital's grain trade other than in terms of aggregate corn imports has disguised the nature and extent of its contribution to the development of the London economy. By the 1680s, the coastal trade comprised two distinct strands of roughly equal size: one providing food and drink for the London population, the other fuelling the overland trade of the capital. It is argued that the former was unnecessary for the provision of the city other than in barren years, but that the latter may have been indispensable for the development of the overland transport infrastructure of the metropolitan region at the height of the late seventeenth-century commercial revolution. Thanks largely to the agency of southern English mariners commanding large coasters, London's demand for fodder crops after the mid-1670s drew most of the coast stretching from Berwick to Whitehaven into the orbit of the metropolitan corn market.

Unbending the mind: or, commercialized leisure and the rhetoric of eighteenth-century diversion

This essay opens by asking why the formative period in the “commercialization of leisure” in England (c. 1690–1760) happens also to be the period during which intrusion, obstruction, and interruption first began to thrive as conspicuous rhetorical techniques in commercial literature. The essay answers this question through a series of close readings that reveal the complex reciprocity between what I call “cultural diversion” and “discursive diversion,” between those social amusements which provide relief from the serious concerns of daily life and those linguistic and textual devices which characteristically disrupt so much of the discourse of the late seventeenth and early eighteenth century—devices such as extravagant metaphors, rows of asterisked ellipses, and, most pervasively, digressions. Where modern discussion of such devices has tended to rely on the critical touch-stone of “self-consciousness,” this essay restores disruptive rhetoric to what I see as its original cultural context by demonstrating how frequently self-conscious authors associate the form and function of devices like digression with London’s “Reigning Diversions.”

The rise of agrarian capitalism and the decline of family farming in England

Historians have documented rising farm sizes throughout the period 1450–1850. Existing studies have revealed much about the mechanisms underlying the development of agrarian capitalism. However, we currently lack any consensus as to when the critical developments occurred. This is largely due to the absence of sufficiently large and geographically wide-ranging datasets but is also attributable to conceptual weaknesses in much of the literature. This article develops a new approach to the problem and argues that agrarian capitalism was dominant in southern and eastern England by 1700 but that in northern England the critical developments came later.

Popular culture and sporting life in the rural margins of late eighteenth-century England: the world of Robert Anderson, "The Cumberland Bard"

This study sets out to extend and challenge existing historiography on late eighteenth century British popular culture, customary sports, class and cultural identity, focusing upon the rural geo-political borderland of England. It suggests that prevailing class-based and more London-biased studies need to be balanced with more regionalist-based work, and shows the importance of northern regional leisure variants. The textual and historical analysis draws largely on the published works of a neglected working-class dialect poet, Robert Anderson, living and working in Cumberland, arguing that he represented a strain of ''bardic regionalism,'' a variant of Katie Trumpener’s ''bardic nationalism.''

Women and children first? The administration of Titanic relief in Southampton, 1912–59

One of the principal narratives woven around the 1912 sinking of the Titanic is that the tragedy united people around the world in a shared sense of horror and grief. This study examines the administration of the relief fund collected for victims and questions the established image of social unity and collective suffering. The records of the Southampton Titanic Relief Fund reveal welfare processes imbued with class and gender prejudices that consigned many of the relatives of victims to poverty-stricken lives, despite the massive fund collected in their names.

"It Was Never Good World Sence Minister Must Have Wyves": clerical celibacy, clerical marriage, and anticlericalism in Reformation England

The impact of the Reformation was felt strongly in the nature and character of the priesthood, and in the function and reputation of the priest. A shift in the understanding of the priesthood was one of the most tangible manifestations of doctrinal change, evident in the physical arrangement of the church, in the language of the liturgy, and in the relaxation of the discipline of celibacy, which had for centuries bound priests in the Latin tradition to a life of perpetual continence. Clerical celibacy, and accusations of clerical incontinence, featured prominently in evangelical criticisms of the Catholic church and priesthood, which made a good deal of polemical capital out of the perceived relationship of the priest and the efficacy of his sacred function. Citing St Paul, Protestant polemicists presented clerical marriage as the only, and appropriate remedy, for priestly immorality. But did the advent of a married priesthood create more problems than it solved? The polemical certainties that informed evangelical writing on sacerdotal celibacy did not guarantee the immediate acceptance of a married priesthood, and the vocabulary that had been used to denounce clergy who failed in their obligation to celibacy was all too readily turned against the married clergy. The anti-clerical lexicon, and its usage, remained remarkably static despite the substantial doctrinal and practical challenges posed to the traditional model of priesthood by the Protestant Reformation.

Prevalence of heart failure and atrial fibrillation in minority ethnic subjects: the Ethnic-Echocardiographic Heart of England Screening Study (E-ECHOES)

BACKGROUND

Limited data exists on the prevalence of heart failure amongst minority groups in the UK. To document the community prevalence and severity of left ventricular systolic dysfunction, heart failure, and atrial fibrillation, amongst the South Asian and Black African-Caribbean groups in the UK.

METHODS AND RESULTS

We conducted a cross-sectional study recruiting from September 2006 to July 2009 from 20 primary care centres in Birmingham, UK. 10,902 eligible subjects invited, 5,408 participated (49.6%) and 5,354 had complete data (49.1%). Subjects had median age 58.2 years (interquartile range 51.0 to 70.0), and 2544 (47.5%) were male. Of these, 1933 (36.3%) had BMI>30 kg/m(2), 1,563 (29.2%) had diabetes, 2676 (50.0%) had hypertension, 307 (5.7%) had a history of myocardial infarction, and 104 (1.9%) had history of arrhythmia. Overall, 59 (1.1%) had an Ejection Fraction<40%, and of these 40 (0.75%) were NYHA class ≥2; 51 subjects (0.95%) had atrial fibrillation. Of the remaining 19 patients with an EF<40%, only 4 patients were treated with furosemide. A further 54 subjects had heart failure with preserved ejection fraction.

CONCLUSIONS

This is the largest study of the prevalence of left ventricular systolic dysfunction, heart failure and atrial fibrillation in under-researched minority communities in the UK. The prevalence of heart failure in these minority communities appears comparable to that of the general population but less than anticipated given the high rates of cardiovascular disease in these groups. Heart failure continues to be a major cause of morbidity in all ethnic groups and preventive strategies need to be identified and implemented.

Comparative risk of microalbuminuria and proteinuria in UK residents of south Asian and white European ethnic background with type 2 diabetes: a report from UKADS

OBJECTIVE

This study investigated and compared the prevalence of microalbuminuria and overt proteinuria and their determinants in a cohort of UK resident patients of white European or south Asian ethnicity with type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

A total of 1978 patients, comprising 1486 of south Asian and 492 of white European ethnicity, in 25 general practices in Coventry and Birmingham inner city areas in England were studied in a cross-sectional study. Demographic and risk factor data were collected and presence of microalbuminuria and overt proteinuria assessed.

TRIAL REGISTRATION NUMBER

ISRCTN 38297969.

MAIN OUTCOME MEASURES

Prevalences of microalbuminuria and overt proteinuria.

RESULTS

Urinary albumin:creatinine measurements were available for 1852 (94%) patients. The south Asian group had a lower prevalence of microalbuminuria, 19% vs. 23% and a higher prevalence of overt proteinuria, 8% vs. 3%, χ(2) = 15.85, 2df, P = 0.0004. In multiple logistic regression models, adjusted for confounding factors, significantly increased risk for the south Asian vs. white European patients for overt proteinuria was shown; OR (95% CI) 2.17 (1.05, 4.49), P = 0.0365. For microalbuminuria, an interaction effect for ethnicity and duration of diabetes suggested that risk for south Asian patients was lower in early years following diagnosis; OR for SA vs. WH at durations 0 and 1 year were 0.56 (0.37, 0.86) and 0.59 (0.39, 0.89) respectively. After 20 years' duration, OR = 1.40 (0.63, 3.08).

LIMITATIONS

Comparability of ethnicity defined groups; statistical methods controlled for differences between groups, but residual confounding may remain. Analyses are based on a single measure of albumin:creatinine ratio.

CONCLUSIONS

There were significant differences between ethnicity groups in risk factor profiles and microalbuminuria and overt proteinuria outcomes. Whilst south Asian patients had no excess risk of microalbuminuria, the risk of overt proteinuria was elevated significantly, which might be explained by faster progression of renal dysfunction in patients of south Asian ethnicity.

Policy entrepreneurship in the development of public sector strategy: the case of London health reform

The development of health policy is recognized as complex; however, there has been little development of the role of agency in this process. Kingdon developed the concept of policy entrepreneur (PE) within his ‘windows’ model. He argued inter-related ‘policy streams' must coincide for important issues to become addressed. The conjoining of these streams may be aided by a policy entrepreneur. We contribute by clarifying the role of the policy entrepreneur and highlighting the translational processes of key actors in creating and aligning policy windows. We analyse the work in London of Professor Sir Ara Darzi as a policy entrepreneur. An important aspect of Darzi's approach was to align a number of important institutional networks to conjoin related problems. Our findings highlight how a policy entrepreneur not only opens policy windows but also yokes together a network to make policy agendas happen. Our contribution reveals the role of clinical leadership in health reform.

"Children of the city": juvenile justice, property, and place in England and Scotland, 1945-60

This article uses cases studies of Dundee and Manchester to explain juvenile property-offending in terms of young people's use of objects and spaces in the period 1945-60. A composite picture is assembled of objects stolen, which reflects growth of the specifically "teenage" consumer market as well as continued significance of young people's contribution to family economies. Concerns about youth, property, and space were reported in newspapers in terms of vandalism and hooliganism. "Play" and "nuisance" were overlapping and contested categories; re-education of young people in the correct use of place, space, and property was a key aim of the postwar juvenile justice system.

Towards developing new partnerships in public services: users as consumers, citizens and/or co-producers in health and social care in England and Sweden

The causes and effects of marketization of public services have been analysed extensively in the literature, but there is relatively little research on how those policies impact on the development of new forms of governance, and the role of users in these new arrangements. This study reviews examples of competition, freedom of choice and personalized care in health and social services in England and Sweden, in order to examine the type of relationships emerging between the user/consumer vis-à-vis market driven providers and various agencies of the state under the marketized welfare. The article focuses on the possible roles users might assume in new hybrid arrangements between markets, collaborations and steering. A user typology: namely, that of a consumer, citizen, co-producer and responsibilized agent in various governance arrangements, is then suggested. The article concludes by arguing that pro-market policies instead of meeting the alleged needs of post-modern users for individualized public services are likely to promote a new type of highly volatile and fragile partnerships, and create a new subordinated user who has no choice but to ‘choose’ services they have little control over.

"It is caused of the womans part or of the mans part": the role of gender in the diagnosis and treatment of sexual dysfunction in early modern England

Philip Barrough wrote in 1590 that barrenness 'is caused of the womans part or of the mans part'. By the eighteenth century, however, barrenness was perceived as a female disorder distinguished from male impotence. Few historians have addressed the uncertainty surrounding early modern definitions of infertility, choosing instead to adopt set terms that fit comfortably with modern ideas. This article will highlight the difficulties surrounding the gender distinction of the terms 'barrenness' and 'impotence' during this period. Moreover, the discussion will examine the role of gender in diagnosing these disorders to sufferers. The article will argue that ideas of gender were more central to diagnosis of poor sexual health than to effectual treatment. Although it appears that barrenness and impotence were treated with separate remedies, many treatments were described as effectual for both sexes. Additionally, the ingredients used in such recipes were often sexual stimulants explained without reference to gender.

Voice and choice in health care in England: understanding citizen responses to dissatisfaction

Using data from a five-year online survey the paper examines the effects of relative satisfaction with health services on individuals' voice-and-choice activity in the English public health care system. Voice is considered in three parts – individual voice (complaints), collective voice voting and participation (collective action). Exercising choice is seen in terms of complete exit (not using health care), internal exit (choosing another public service provider) and private exit (using private health care). The interaction of satisfaction and forms of voice and choice are analysed over time. Both voice and choice are correlated with dissatisfaction with those who are unhappy with the NHS more likely to privately voice and to plan to take up private health care. Those unable to choose private provision are likely to use private voice. These factors are not affected by items associated with social capital – indeed, being more trusting leads to lower voice activity.

Nursery schools for the few or the many? Childhood, education and the state in mid-twentieth-century England

Prior to the outbreak of the Second World War, successive presidents and officials at the Board of Education made it clear that they believed there were three types of children in Britain - those who needed nursery schools to rescue them from degradation, those for whom a less expensive nursery class would do the job adequately and those who would be better off staying home with mother. However, by the time the 1944 Education Act was framed, national policy towards pre-school provision had undergone a major transformation: nursery schools could provide the best start in life for everyone, should be available for every child from three to five and, crucially, should be the only form of childcare provision available. This change of direction was initiated by the government's inspectorate, and heavily promoted by members of the civil service. Professional bodies, such as the Nursery School Association and teaching unions, had very little influence over the decision-making process. The needs of working mothers, who were likely to be adversely affected by the closure of wartime childcare facilities, were inadequately considered. Local Education Authorities, who generally favoured nursery classes, were, however, able to wring a last-minute compromise from central government so that classes could be provided where schools were “inexpedient”. The fact that the new policy had been written in such isolation, without consideration for potential users, and had been messily hamstrung at the last moment meant that it was never implemented and must ultimately be considered a failure.