Effects on mental health of a UK welfare reform, Universal Credit: a longitudinal controlled study

Effect of same-sex marriage legalisation on the health of ethnic minority lesbian, gay and bisexual people: a quasi-experimental study

BACKGROUND

The UK legalised same-sex marriage in 2014. We examine whether same-sex marriage legalisation (SSML), an exogenous policy change, affected the health outcomes among ethnic minority lesbian, gay, bisexual and other (LGB+) individuals.

METHODS

Using the UK Household Longitudinal Survey, we applied the Callaway and Sant'Anna difference-in-differences to compare physical and mental health across (a) ethnic LGB+ individuals (treatment group), (b) ethnic heterosexual individuals (control group 1) and (c) British white LGB+ individual (control group 2). The study cohort (n=7054) comprised individuals aged 16+ years at baseline in 2011, and were employed in the study period (2011-2019). The outcomes included physical component scores from the short-form 12 health survey (physical component score (PCS-12)), long-standing illnesses and psychological distress (General Health Questionnaire (GHQ)).

RESULTS

After SSML, the PCS-12 among the ethnic LGB+ individuals improved significantly compared with both ethnic heterosexuals and British white LGB+ individuals (2.081, 95% CI 0.487 to 3.675). While no clear patterns were found for long-standing illnesses, the GHQ in the treatment group had modest decreases relative to ethnic heterosexuals, and relative to British white LGB+ individuals, by year 2 after SSML.

CONCLUSION

SSML in the UK led to improved physical functioning and reduced psychological distress in ethnic minority LGB+ individuals. Our study shows that ethnic LGB+ individuals may derive even greater health benefits than British white LGB+ people, providing evidence that SSML may help address racial health inequalities within LGB+ communities. As countries worldwide consider legalising same-sex marriage, it is imperative for policymakers to consider the health consequences for sexual and ethnic minorities.

Effect of Universal Credit on young children's mental health: quasi-experimental evidence from Understanding Society

BACKGROUND

Child mental health has become an increasingly important issue in the UK, especially in the context of significant welfare reforms. Universal Credit (UC) has introduced substantial changes to the UK's social security system, significantly impacting low-income families. Our aim was to assess the effects of UC's introduction on children's mental health for families eligible for UC versus a comparable non-eligible sample.

METHODS

Using Understanding Society data from 5806 observations of 4582 children (aged 5 or 8 years) in Great Britain between 2012 and 2018, we created two groups: children whose parents were eligible for UC (intervention group) and children whose parents were ineligible for UC (comparison group). Child mental health was assessed using a parent-reported Strengths and Difficulties Questionnaire. The OR and percentage point change in the prevalence of children experiencing mental health difficulties between the intervention group and the comparison group following the introduction of UC were analysed. We also investigated whether the utilisation of childcare services and changes in household income were mechanisms by which UC impacted children's mental health.

RESULTS

Logistic regression results demonstrated that the prevalence of mental health problems among eligible children whose parents were unemployed increased by an OR of 2.18 (95% CI 1.14 to 4.18), equivalent to an 8-percentage point increase (95% CI 1 to 14 percentage points) following the introduction of UC, relative to the comparison group. Exploring potential mechanisms, we found neither reduced household income nor increased use of childcare services, which served as a proxy for reduced time spent with parents, significantly influenced children's mental health.

CONCLUSIONS

UC has led to an increase in mental health problems among recipient children, particularly for children in larger families and those aged 8. Policymakers should carefully evaluate the potential health consequences for specific demographics when introducing new welfare policies.

Universal Credit receipt among working-age patients who are accessing specialist mental health services: results from a novel data linkage study

BACKGROUND

In 2013, Universal Credit (UC) was introduced by the UK Government. Understanding of how UC provision is allocated among people with mental disorders, and its intersection with protected characteristics is limited. This study aimed to explore (1) how UC receipt, including UC conditionality regime, varied among users of specialist mental health services between 2013 and 2019 and (2) associations between sociodemographic and diagnostic patient characteristics and UC receipt.

METHODS

Working-age individuals who had accessed specialist mental health services were included if they had their mental health record data successfully linked with administrative benefits data. Associations between sociodemographic, diagnostic patient characteristics and UC receipt were explored using logistic regression models.

RESULTS

Of the 143 715 patients, 26.9% had received UC between 2013 and 2019. Four in five patients were allocated to the searching for work conditionality regime during their time on UC. Females were less likely to have received UC (adjusted OR (AOR) 0.87, 95% CI 0.85 to 0.89) than males, and UC receipt decreased with age. Black patients (AOR 1.39, 95% CI 1.34 to 1.44) and patients from mixed and multiple ethnic backgrounds (AOR 1.27, 95% CI 1.18 to 1.38) had a higher likelihood of UC receipt than White patients. UC receipt was lower among patients diagnosed with severe mental illness compared with other psychiatric diagnoses (AOR 0.74, 95% CI 0.71 to 0.77).

CONCLUSION

One in four specialist mental health service users had received UC and a large majority were subject to conditionality. The temporality of UC conditionality and mental health service presentation needs further exploration.

A Bayesian Interrupted Time Series framework for evaluating policy change on mental well-being: An application to England's welfare reform

Factors contributing to social inequalities are associated with negative mental health outcomes and disparities in mental well-being. We propose a Bayesian hierarchical controlled interrupted time series to evaluate the impact of policies on population well-being whilst accounting for spatial and temporal patterns. Using data from the UKs Household Longitudinal Study, we apply this framework to evaluate the impact of the UKs welfare reform implemented in the 2010s on the mental health of the participants, measured using the GHQ-12 index. Our findings indicate that the reform led to a 2.36% (95% CrI: 0.57%-4.37%) increase in the national GHQ-12 index in the exposed group, after adjustment for the control group. Moreover, the geographical areas that experienced the largest increase in the GHQ-12 index are from more disadvantage backgrounds than affluent backgrounds.

What Are the Roots of the Nation's Poor Health and Widening Health Inequalities? Rethinking Economic Growth for a Fairer and Healthier Future

Health inequalities are differences in health between groups in society. Despite them being preventable they persist on a grand scale. At the beginning of 2024, the Institute of Health Equity revealed in their report titled: Health Inequalities, Lives Cut Short, that health inequalities caused 1 million early deaths in England over the past decade. While the number of studies on the prevalence of health inequalities in the UK has burgeoned, limited emphasis has been given to exploring the factors contributing to these (widening) health inequalities. In this commentary article I will describe how the Government's relentless pursuit of economic growth and their failure to implement the necessary regulatory policies to mitigate against the insecurity and health effects neoliberal free market capitalism (referred to as capitalism herein) causes in pursuit of innovation, productivity and growth (economic dynamism) is one key driver underpinning this social injustice. I contend that if the priority really is to tackle health inequalities and ensure health for all then there is an imperative need to move beyond regulation alone to mitigate the worst effects of capitalist production; the goal of the economy has to change to fully restore the balance between economic growth and public health.

Methodological approaches to measuring mental health in a cost-of-living crisis: A rapid review

BACKGROUND

Cost-of-living crises are damaging to population mental health and require a public health response. It is important to assess whether public health interventions are effective. We aimed to identify population-level methods and measures and the appropriateness of the measures for vulnerable populations.

METHODS

A rapid evidence review was undertaken. Nineteen databases, including grey literature, were searched for evidence published between 1970 and April 2023.

RESULTS

Seven reviews, nine primary studies and two reports from grey literature were identified. Methods consisted of analyses of existing data from national or regional cohort studies, household panel surveys, repeated cross-sectional surveys, routine medical data, or data on suicide death rates. Twelve brief validated mental health measurement tools, embedded in population-level surveys, were identified. Two quasi-experimental studies used data from a UK household panel survey to examine the impact of the introduction of specific welfare policies on mental health. Studies identified socio-economic vulnerabilities, but it was not possible to determine whether data were effectively captured from people from minority ethnic groups.

CONCLUSION

Population-level surveys can be used in quasi-experimental studies to measure the effects of a public health initiative with specific roll out dates to tackle cost-of-living impacts. It is unclear as to whether the identified methods and tools are suitable for use with people from minority ethnic groups.

Employment support for Black people with long-term health conditions: a systematic narrative review of UK studies

BACKGROUND

Black people in the United Kingdom disproportionately acquire long-term health conditions and are marginalised from the labour market compared with other groups. These conditions interact and reinforce high rates of unemployment among Black people with long-term health conditions.

AIMS

To examine the efficacy, and experience, of employment support interventions in meeting the needs of Black service users in Britain.

METHODS

A systematic literature search was conducted focusing on peer-reviewed literature featuring samples drawn from the United Kingdom.

RESULTS

The literature search revealed a paucity of articles that include analysis of Black people's outcomes or experiences. Six articles met the selection criteria of the review, of which five focused on mental health impairments. No firm conclusions could be drawn from the systematic review; however, the evidence suggests that Black people are less likely than their White counterparts to secure competitive employment and that Individual Placement and Support (IPS) may be less effective for Black participants.

CONCLUSIONS

We argue for a greater focus on ethnic differences in employment support outcomes with an emphasis on how such services may remediate racial differences in employment outcomes. We conclude by foregrounding how structural racism may explain the dearth of empirical evidence in this review.

Impact of Parental Mental Health and Poverty on the Health of the Next Generation: A Multi-Trajectory Analysis Using the UK Millennium Cohort Study

PURPOSE

Exposure to parental mental ill-health and poverty in childhood impact health across the lifecourse. Both maternal and paternal mental health may be important influences, but few studies have unpicked the complex interrelationships between these exposures and family poverty for later health.

METHODS

We used longitudinal data on 10,500 children from the nationally representative UK millennium cohort study. Trajectories of poverty, maternal mental health, and secondary caregiver mental health were constructed from child age of 9 months through to 14 years. We assessed the associations of these trajectories with mental health outcomes at the age of 17 years. Population-attributable fractions were calculated to quantify the contribution of caregivers' mental health problems and poverty to adverse outcomes at the country level.

RESULTS

We identified five distinct trajectories. Compared with children with low poverty and good parental mental health, those who experienced poverty and poor primary or secondary caregiver mental health (53%) had worse outcomes. Children exposed to both persistent poverty and poor caregiver mental health were at markedly increased risk of socioemotional behavioural problems (aOR 4.2; 95% CI 2.7-6.7), mental health problems (aOR 2.5; CI 1.6-3.9), and cognitive disability (aOR 1.7; CI 1.1-2.5). We estimate that 40% of socioemotional behavioural problems at the age of 17 were attributable to persistent parental caregivers' mental health problems and poverty.

DISCUSSION

More than half of children growing up in the UK are persistently exposed to either one or both of poor caregiver mental health and family poverty. The combination of these exposures is strongly associated with adverse health outcomes in the next generation.

Contributions of residential traffic noise to depression and mental wellbeing in Hong Kong: A prospective cohort study

Prior studies on the association between traffic noise and mental health have been mostly conducted in settings with lower population densities. However, evidence is lacking in high population-density settings where traffic noise is more pervasive and varies by topography and the vertical elevation of the residential unit. This study aimed to assess the mental health impact of residential traffic noise in one of the world's most urbanised populations. Data were analysed from 13,401 participants aged ≥15 years in a prospective cohort in Hong Kong from 2009 to 2014. Residential traffic noise level was estimated using 3D-geocoding and validated models that accounted for sound propagation in a highly vertical landscape. The 24-h day-night exposure to traffic noise, denoted as Ldn, was estimated with a 10-dB(A) penalty for night hours. Probable depression and mental wellbeing were assessed using the Patient Health Questionnaire-9 and the Short Form Health Questionnaire SF-12v2, respectively. Mixed effect regressions with random intercepts were used to examine the association between traffic noise and mental health outcomes. Residential road traffic noise (for each increment of 10 A-weighted decibels [dB(A)] 24-h average exposure) was associated with probable depression (odds ratio (OR) = 1.17, 95% CI: 1.05, 1.31), and poorer mental wellbeing (mean difference = -0.19, 95% CI: 0.31, -0.06), adjusting for sociodemographics, smoking, body mass index, self-reported health, proximity to green space, and neighbourhood characteristics (average household income, population density, and Gini coefficient). The results were robust to further adjustment for air pollution. In stratified analyses, residential traffic noise was associated with probable depression and poorer mental wellbeing among students and individuals aged 15-34 years. Residential traffic noise was associated with probable depression and poorer mental wellbeing in a highly urbanised setting. As traffic noise is increasing in urban settings, the public health impact of noise pollution could be substantial.

Social security cuts and life expectancy: a longitudinal analysis of local authorities in England, Scotland and Wales

BACKGROUND

The UK Government's 'welfare reform' programme included reductions to social security payments, phased in over the financial years 2011/2012-2015/2016. Previous studies of social security cuts and health outcomes have been restricted to analysing single UK countries or single payment types (eg, housing benefit). We examined the association between all social security cuts fully implemented by 2016 and life expectancy, for local authorities in England, Scotland and Wales.

METHODS

Our unit of analysis was 201 upper tier local authorities (unitary authorities and county councils: 147 in England, 32 in Scotland, 22 in Wales). Our exposure was estimated social security loss per head of the working age population per year for each local authority, calculated against the baseline in 2010/2011. The primary outcome was annual life expectancy at birth between the calendar years 2012 and 2016 (year lagged following exposure). We used a panel regression approach with fixed effects.

RESULTS

Social security cuts implemented by 2016 were estimated to be £475 per head of the working age population in England, £390 in Scotland and £490 in Wales since 2010/2011. During the study period, there was either no improvement or only marginal increases in national life expectancy. Social security loss and life expectancy were significantly associated: an estimated £100 decrease in social security per head of working age population was associated with a 1-month reduction in life expectancy.

CONCLUSIONS

Social security cuts, at the UK local authority level, were associated with lower life expectancy. Further research should examine causality.

Investigating health and social outcomes of the Big Local community empowerment initiative in England: a mixed method evaluation

Background

Most research on community empowerment provides evidence on engaging communities for health promotion purposes rather than attempts to create empowering conditions. This study addresses this gap.

Intervention

Big Local started in 2010 with £271M from the National Lottery. Ending in 2026, it gives 150 relatively disadvantaged communities in England control over £1M to improve their neighbourhoods.

Objective

To investigate health and social outcomes, at the population level and among engaged residents, of the community engagement approach adopted in a place-based empowerment initiative.

Study design, data sources and outcome variables

This study reports on the third wave of a longitudinal mixed-methods evaluation. Work package 1 used a difference-in-differences design to investigate the impact of Big Local on population outcomes in all 150 Big Local areas compared to matched comparator areas using secondary data. The primary outcome was anxiety; secondary outcomes included a population mental health measure and crime in the neighbourhood. Work package 2 assessed active engagement in Big Local using cross-sectional data and nested cohort data from a biannual survey of Big Local partnership members. The primary outcome was mental well-being and the secondary outcome was self-rated health. Work package 3 conducted qualitative research in 14 Big Local neighbourhoods and nationally to understand pathways to impact. Work package 4 undertook a cost-benefit analysis using the life satisfaction approach to value the benefits of Big Local, which used the work package 1 estimate of Big Local impact on life satisfaction.

Results

At a population level, the impacts on 'reporting high anxiety' (-0.8 percentage points, 95% confidence interval -2.4 to 0.7) and secondary outcomes were not statistically significant, except burglary (-0.054 change in z-score, 95% confidence interval -0.100 to -0.009). There was some effect on reduced anxiety after 2017. Areas progressing fastest had a statistically significant reduction in population mental health measure (-0.053 change in z-score, 95% confidence interval -0.103 to -0.002). Mixed results were found among engaged residents, including a significant increase in mental well-being in Big Local residents in the nested cohort in 2018, but not by 2020; this is likely to be COVID-19. More highly educated residents, and males, were more likely to report a significant improvement in mental well-being. Qualitative accounts of positive impacts on mental well-being are often related to improved social connectivity and physical/material environments. Qualitative data revealed increasing capabilities for residents' collective control. Some negative impacts were reported, with local factors sometimes undermining residents' ability to exercise collective control. Finally, on the most conservative estimate, the cost-benefit calculations generate a net benefit estimate of £64M.

Main limitations

COVID-19 impacted fieldwork and interpretation of survey data. There was a short 4-year follow-up (2016/20), no comparators in work package 2 and a lack of power to look at variations across areas.

Conclusions

Our findings suggest the need for investment to support community organisations to emerge from and work with communities. Residents should lead the prioritisation of issues and design of solutions but not necessarily lead action; rather, agencies should work as equal partners with communities to deliver change.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research Programme (16/09/13) and will be published in full in Public Health Research; Vol. 11, No. 9. See the NIHR Journals Library website for further project information.

A scoping review of trauma informed approaches in acute, crisis, emergency, and residential mental health care

Experiences of trauma in childhood and adulthood are highly prevalent among service users accessing acute, crisis, emergency, and residential mental health services. These settings, and restraint and seclusion practices used, can be extremely traumatic, leading to a growing awareness for the need for trauma informed care (TIC). The aim of TIC is to acknowledge the prevalence and impact of trauma and create a safe environment to prevent re-traumatisation. This scoping review maps the TIC approaches delivered in these settings and reports related service user and staff experiences and attitudes, staff wellbeing, and service use outcomes.We searched seven databases (EMBASE; PsycINFO; MEDLINE; Web of Science; Social Policy and Practice; Maternity and Infant Care Database; Cochrane Library Trials Register) between 24/02/2022-10/03/2022, used backwards and forwards citation tracking, and consulted academic and lived experience experts, identifying 4244 potentially relevant studies. Thirty-one studies were included.Most studies (n = 23) were conducted in the USA and were based in acute mental health services (n = 16). We identified few trials, limiting inferences that can be drawn from the findings. The Six Core Strategies (n = 7) and the Sanctuary Model (n = 6) were the most commonly reported approaches. Rates of restraint and seclusion reportedly decreased. Some service users reported feeling trusted and cared for, while staff reported feeling empathy for service users and having a greater understanding of trauma. Staff reported needing training to deliver TIC effectively.TIC principles should be at the core of all mental health service delivery. Implementing TIC approaches may integrate best practice into mental health care, although significant time and financial resources are required to implement organisational change at scale. Most evidence is preliminary in nature, and confined to acute and residential services, with little evidence on community crisis or emergency services. Clinical and research developments should prioritise lived experience expertise in addressing these gaps.

Reconsidering economic interventions to reduce oral health inequalities

Despite the general recognition of economic factors as fundamental upstream social determinants of health inequalities, interventions to improve health and reduce inequalities tend to focus on proximal health determinants. However, recent socioeconomic crises have increased the focus on economic factors. Health-related approaches to address economic factors can be divided into two categories: (1) indirect approaches, such as financial support for obtaining dental care and fiscal policies targeting unhealthy commodities and (2) direct approaches, such as cash transfers or provision of a universal basic income. For indirect approaches, policies reducing out-of-pocket payments for dental care appear to improve access to services and reduce oral health inequalities. Price policies targeting tobacco and sugar through taxation are associated with declines in periodontal disease and caries, and sugar taxation appears to reduce oral health inequalities. As regards direct approaches, studies on cash transfers to low-income individuals have found no positive impact on dental visits, while results in relation to caries prevention were inconclusive. No dental studies examined the effect of a population approach to income security, such as basic income. Research on economic interventions for oral health inequalities is scarce, and studies using causal inference methods and natural experiments are urgently needed.

Mental health impact of cuts to local government spending on cultural, environmental and planning services in England: a longitudinal ecological study

BACKGROUND

Over the past decade, there have been significant and unequal cuts to local authority (LA) budgets, across England. Cultural, environmental and planning (CEP) budgets have been cut by 17% between 2011 and 2019. This funding supports services such as parks, leisure centres, community development and libraries, all of which have potential to influence population mental health. We therefore investigated whether cuts to CEP services have affected mental health outcomes and the extent to which they have contributed to mental health inequalities between areas.

METHODS

Using fixed effects regression applied to longitudinal LA-level panel data in England, we assessed whether trends in CEP spend were associated with trends in mental health outcomes, between 2011 and 2019. The exposure was CEP spend and the primary outcome was the LA-average Small Area Mental Health Index (SAMHI). Additionally, we considered subcategories of CEP spend as secondary exposures, and antidepressant prescription rate and self-reported anxiety levels as secondary outcomes, both aggregated to LA-level. We adjusted all models for confounders and conducted subgroup analysis to examine differential mental health effects of spending cuts based on the level of area deprivation.

RESULTS

The average decrease in CEP spend of 15% over the period was associated with a 0.036 (95% CI: 0.005, 0.067) increase in SAMHI score, indicating worsening mental health. Amongst subcategories of CEP spending, cuts to planning and development services impacted mental health trends the most, with a 15% reduction in spend associated with a 0.018 (95% CI: 0.005, 0.031) increase in the SAMHI score. The association between cuts in CEP and deteriorating mental health was greater in more affluent areas.

CONCLUSION

Cuts to spending on cultural, environmental, planning and development services were associated with worsening population mental health in England. Impacts were driven by cuts to planning and development services in particular. Reinvesting in these services may contribute to improved public mental health.

Trends in psychological distress in Great Britain, 1991-2019: evidence from three representative surveys

BACKGROUND

Previously improving UK mortality trends stalled around 2012, with evidence implicating economic policy as the cause. This paper examines whether trends in psychological distress across three population surveys show similar trends.

METHODS

We report the percentages reporting psychological distress (4+ in the 12-item General Health Questionnaire) from Understanding Society (Great Britain, 1991-2019), Scottish Health Survey (SHeS, 1995-2019) and Health Survey for England (HSE, 2003-2018) for the population overall, and stratified by sex, age and area deprivation. Summary inequality indices were calculated and segmented regressions fitted to identify breakpoints after 2010.

RESULTS

Psychological distress was higher in Understanding Society than in SHeS or HSE. There was slight improvement between 1992 and 2015 in Understanding Society (with prevalence declining from 20.6% to 18.6%) with some fluctuations. After 2015 there is some evidence of a worsening in psychological distress across surveys. Prevalence worsened notably among those aged 16-34 years after 2010 (all three surveys), and aged 35-64 years in Understanding Society and SHeS after 2015. In contrast, the prevalence declined in those aged 65+ years in Understanding Society after around 2008, with less clear trends in the other surveys. The prevalence was around twice as high in the most deprived compared with the least deprived areas, and higher in women, with trends by deprivation and sex similar to the populations overall.

CONCLUSION

Psychological distress worsened among working-age adults after around 2015 across British population surveys, mirroring the mortality trends. This indicates a widespread mental health crisis that predates the COVID-19 pandemic.

Exploring the health and sociodemographic characteristics of people seeking advice with claiming universal credit: a cross-sectional analysis of UK citizens advice data, 2017-2021

BACKGROUND

The UK Department for Work and Pensions (DWP) administers Universal Credit (UC) - the main UK benefit for people in- and out-of-work. UC is being rolled out nationally from 2013 to 2024. Citizens Advice (CA) is an independent charity that provides advice and support to people making a claim for UC. The aim of this study is to understand who is seeking advice from CA when making a UC claim and how the types of people seeking advice are changing as the rollout of UC continues.

METHODS

Co-developed with Citizens Advice Newcastle and Citizens Advice Northumberland we performed longitudinal analysis of national data from Citizens Advice for England and Wales on the health (mental health and limiting long term conditions) and socio-demographic of 1,003,411 observations for people seeking advice with claiming UC over four financial years (2017/18 to 2020/21). We summarised population characteristics and estimated the differences between the four financial years using population-weighted t-tests. Findings were discussed with three people with lived experience of seeking advice to claim UC to help frame our interpretation and policy recommendations.

RESULTS

When comparing 2017/18 to 2018/19, there was a significantly higher proportion of people with limiting long term conditions seeking advice with claiming UC than those without (+ 2.40%, 95%CI: 1.31-3.50%). However, as the rollout continued between 2018/29 and 2019/20 (-6.75%, 95%CI: -9.62%--3.88%) and between 2019/20 and 2020/21 (-2.09%, 95%CI: -2.54%--1.64%), there were significantly higher proportions of those without a limiting long term condition seeking advice than with. When comparing 2018/19 to 2019/20 and 2019/20 to 2020/21, there was a significant increase in the proportion of self-employed compared to unemployed people seeking advice with claiming UC (5.64%, 95%CI: 3.79-7.49%) and (2.26%, 95%CI: 1.29-3.23%) respectively.

CONCLUSION

As the rollout for UC continues, it is important to understand how changes in eligibility for UC may impact on those who need help with applying for UC. Ensuring that the advice process and application process is responsive to a range of people with different needs can help to reduce the likelihood that the process of claiming UC will exacerbate health inequalities.

Designing a generic, adaptive protocol resource for the measurement of health impact in cash transfer pilot and feasibility studies and trials in high-income countries

INTRODUCTION

In the context of the COVID-19 pandemic, upstream interventions that tackle social determinants of health inequalities have never been more important. Evaluations of upstream cash transfer trials have failed to capture comprehensively the impacts that such systems might have on population health through inadequate design of the interventions themselves and failure to implement consistent, thorough research measures that can be used in microsimulations to model long-term impact. In this article, we describe the process of developing a generic, adaptive protocol resource to address this issue and the challenges involved in that process. The resource is designed for use in high-income countries (HIC) but draws on examples from a UK context to illustrate means of development and deployment. The resource is capable of further adaptation for use in low- and middle-income countries (LMIC). It has particular application for trials of Universal Basic Income but can be adapted to those covering other kinds of cash transfer and welfare system changes.

METHODS

We outline two types of prospective intervention based on pilots and trials currently under discussion. In developing the remainder of the resource, we establish six key principles, implement a modular approach based on types of measure and their prospective resource intensity, and source (validated where possible) measures and baseline data primarily from routine collection and large, longitudinal cohort studies. Through these measures, we seek to cover all areas of health impact identified in our theoretical model for use in pilot and feasibility studies.

RESULTS

We find that, in general, self-reported measures alongside routinely collected linked respondent data may provide a feasible means of producing data capable of demonstrating comprehensive health impact. However, we also suggest that, where possible, physiological measures should be included to elucidate underlying biological effects that may not be accurately captured through self-reporting alone and can enable modelling of long-term health outcomes. In addition, accurate self-reported objective income data remains a challenge and requires further development and testing. A process of development and implementation of the resource in pilot and feasibility studies will support assessment of whether or not our proposed health outcome measures are acceptable, feasible and can be used with validity and reliability in the target population.

DISCUSSION

We suggest that while Open Access evaluation instruments are available and usable to measure most constructs of interest, there remain some areas for which further development is necessary. This includes self-reported wellbeing measures that require paid licences but are used in a range of nationally important longitudinal studies instead of Open Access alternatives.

Associations Between Self-reported Inhibitory Control, Stress, and Alcohol (Mis)use During the First Wave of the COVID-19 Pandemic in the UK: a National Cross-sectional Study Utilising Data From Four Birth Cohorts

We explored (1) self-reported changes in alcohol use during the pandemic in the UK and (2) the extent to which self-reported inhibitory control and/or stress were associated with any change in drinking behaviour. We used a UK-based cross-sectional online survey administered to four nationally representative birth cohorts (N = 13,453). A significant minority of 30- (29.08%) and 50-year-olds (26.67%) reported drinking more, and between 32.23 and 45.02% of respondents reported feeling more stressed depending on the cohort. Stress was associated with hazardous drinking among 30-year-olds (OR = 3.77, 95% CI 1.15 to 12.28). Impatience was associated with both increased alcohol use (1.14, 95% CI 1.06, 1.24) and hazardous drinking (1.20, 95% CI 1.05, 1.38) among 19-year-olds. Risk-taking was associated with hazardous drinking for 30-year-olds (OR = 1.18, 95% CI 1.05, 1.32). These data highlight concerns for those at risk of alcohol misuse and alcohol-related harm during COVID-19 lockdowns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11469-021-00599-8.

Bearing the burden of austerity: how do changing mortality rates in the UK compare between men and women?

BACKGROUND

Mortality rates across the UK stopped improving in the early 2010s, largely attributable to UK Government's 'austerity' policies. Such policies are thought to disproportionately affect women in terms of greater financial impact and loss of services. The aim here was to investigate whether the mortality impact of austerity-in terms of when rates changed and the scale of excess deaths-has also been worse for women.

METHODS

All-cause mortality data by sex, age, Great Britain (GB) nation and deprivation quintile were obtained from national agencies. Trends in age-standardised mortality rates were calculated, and segmented regression analyses used to identify break points between 1981 and 2019. Excess deaths were calculated for 2012-2019 based on comparison of observed deaths with numbers predicted by the linear trend for 1981-2011.

RESULTS

Changes in trends were observed for both men and women, especially for those living in the 20% most deprived areas. In those areas, mortality increased between 2010/2012 and 2017/2019 among women but not men. Break points in trends occurred at similar time points. Approximately 335 000 more deaths occurred between 2012 and 2019 than was expected based on previous trends, with the excess greater among men.

CONCLUSIONS

It remains unclear whether there are sex differences in UK austerity-related health effects. Nonetheless, this study provides further evidence of adverse trends in the UK and the associated scale of excess deaths. There is a clear need for such policies to be reversed, and for policies to be implemented to protect the most vulnerable in society.

Is austerity a cause of slower improvements in mortality in high-income countries? A panel analysis

BACKGROUND

The rate of improvement in mortality slowed across many high-income countries after 2010. Following the 2007-08 financial crisis, macroeconomic policy was dominated by austerity as countries attempted to address perceived problems of growing state debt and government budget deficits. This study estimates the impact of austerity on mortality trends for 37 high-income countries between 2000 and 2019.

METHODS

We fitted a suite of fixed-effects panel regression models to mortality data (period life expectancy, age-standardised mortality rates (ASMRs), age-stratified mortality rates and lifespan variation). Austerity was measured using the Alesina-Ardagna Fiscal Index (AAFI), Cyclically-Adjusted Primary Balance (CAPB), real indexed Government Expenditure, and Public Social Spending as a % of GDP. Sensitivity analyses varied the lag times, and confined the panel to economic downturns and to non-oil-dominated economies.

RESULTS

Slower improvements, or deteriorations, in life expectancy and mortality trends were seen in the majority of countries, with the worst trends in England & Wales, Estonia, Iceland, Scotland, Slovenia, and the USA, with generally worse trends for females than males. Austerity was implemented across all countries for at least some time when measured by AAFI and CAPB, and for many countries across all four measures (and particularly after 2010). Austerity adversely impacted life expectancy, ASMR, age-specific mortality and lifespan variation trends when measured with Government Expenditure, Public Social Spending and CAPB, but not with AAFI. However, when the dataset was restricted to periods of economic downturn and in economies not dominated hydrocarbon production, all measures of austerity were found to reduce the rate of mortality improvement.

INTERPRETATION

Stalled mortality trends and austerity are widespread phenomena across high-income countries. Austerity is likely to be a cause of stalled mortality trends. Governments should consider alternative economic policy approaches if these harmful population health impacts are to be avoided.

Investigating the impact on mental wellbeing of an increase in pensions: A longitudinal analysis by area-level deprivation in England, 1998-2002

In 1997 approximately two million people aged 60 years or over were living poverty in the UK. In 1999 the UK Government raised real pension incomes of low-income pensioners by around a third through the introduction of the Minimum Income Guarantee (MIG). This study explores the implications of this change for pensioners' mental wellbeing with a focus on differences by area level deprivation in England. We explore mental wellbeing outcomes of 205 men (750 person-year observations) and 367 women (1,336 person-year observations) of state pension age from scores on the General Health Questionnaire from the British Household Panel Survey using a panel difference-in-difference estimation procedure. We compare the mental wellbeing of pensioners receiving MIG to that of low-income pensioners not claiming MIG, from 1998 to 2002. To investigate differences by area deprivation we use quintiles of the of the distributions of the 2000 and 2019 local-authority-level English Index of Multiple Deprivation. Models controlled for age, marital status and year. Between 1998 and 2002, 136 (38%) of low-income women and 57 (28%) of low-income men in the sample were claiming MIG at any one time. Income increased by 31% for men and 22% for women. There was no change in mental wellbeing for women but we found an improvement for men overall and for men living in the most deprived areas, in the latter case with a decrease of the GHQ-12 score of 2.43 points (95% CI: -5.49, 0.02). This estimate was similar across all measures of deprivation, and across both years of IMD. This study provides tentative evidence that the increase in pension income in England for low-income pensioners contributed to a reduction of inequalities in mental wellbeing for men. This needs to be considered in terms of future state pension policies.

"I think people have been in survival mode": a qualitative study of community connectivity in a neighbourhood of North East England before and during COVID-19

OBJECTIVES

The aim of the study was to examine whether and how community-centred approaches facilitate community connectivity by exploring changes that matter to communities.

DESIGN

Qualitative study comprising ethnographic methods, participant observation and interviews.Setting Economically deprived neighbourhood of North East England.

PARTICIPANTS

Interviews with community members (n=14) and staff and stakeholders (n=14) involved in a National Lottery Community-funded initiative and 567 hours of participatory observation were undertaken between September 2019 and July 2020. Data were thematically analysed using a community-centred public health framework.

RESULTS

Communities experiencing disadvantage approached the pandemic adversely affected by stigma, austerity and reductions in public sector funding. Community members' priorities centred on the environment, housing, activities for children and young people, crime, community safety and area reputation. Multiagency efforts to promote connectivity, led by voluntary and community sector organisations, were prerequisites in community-centred approaches to public health. Stakeholders reported that these approaches can help alleviate some of the health, social and financial burdens facing communities that are marginalised. Findings suggest community-centred responses were facilitated by trusting relationships, visionary leadership and lived experience of adversity among staff. Issues which appeared to hamper progress included interorganisational power dynamics and attempts to impose solutions. The strength of stakeholders' connections to the area and to people living there contributed to laying the foundations for local responses to the COVID-19 pandemic. Relational, values-informed work with communities provided a platform to mobilise recovery assets.

CONCLUSIONS

Whole-system approaches, codesigned with communities most affected, can help address the long-term consequences of COVID-19 and its negative effects on health and social inequalities. Further comparative implementation research is needed to examine the partnerships, values and principles that drive success and inclusion.

Trends in healthy life expectancy in the age of austerity

BACKGROUND

Worrying changes in life expectancy trends have been observed recently in the UK, largely attributed to austerity policies introduced over the last decade. To incorporate changes to quality, rather than just length of, life, our aim was to describe trends in healthy life expectancy (HLE) for the relevant period.

METHODS

In the absence of available long-term trends, we calculated new estimates of HLE for Scotland for the period 1995-2019, using standard HLE methodologies based on mortality and national survey data, and stratified by sex and socioeconomic deprivation.

RESULTS

Overall, male and female HLE increased markedly between 1995 and 2009, but then decreased by approximately 2 years between 2011 and 2019. A decline was observed for the most and least deprived groups, but this was larger for those living in the 20% most deprived areas, where the decrease was 3.5 years.

CONCLUSIONS

Our findings are further evidence of changing levels of pre-pandemic population health in the UK. An increasing body of UK and international evidence have attributed these changes to UK Government austerity policies. There is an urgent need, therefore, to reverse cuts to social security and protect the income and health of the poorest across all of the UK.

Exploring potential for occupational therapy practice models within areas of social deprivation: A qualitative inquiry within a community-centred food cooperative

Background

A health inequalities gap exists between wealthy and deprived areas. Community-level occupation-focused interventions may support citizens and address inequities within their environments. Since the global financial crash of 2008 and fiscal policy changes within the United Kingdom, there has been a rise in food insecurity. Community volunteer initiatives have responded by providing for their residents. The aim of this study was to explore how occupational therapists may be agents for social change through exploring perspectives of members and volunteers from a community food cooperative in an area of social deprivation.

Methods

Eight semi-structured interviews were conducted with cooperative members and volunteers within a food cooperative established to address food insecurity in a local community. Data were analysed using thematic analysis.

Results

We found three main themes: It’s Not a Foodbank, Shared Hardship and a cross-cutting theme of Community. The results suggest occupation-focused responses can support the development of community and collective occupations thereby contributing solutions to shared problems.

Conclusion

A community-centred, rights-based approach has supported local community need where socio-economic disadvantage and health inequalities were identified. Scope exists for occupational therapists to work genuinely with (not for) communities to address occupational injustice through collective occupation.

Evaluation of the mental health impacts of Universal Credit: protocol for a mixed methods study

INTRODUCTION

The UK social security system is being transformed by the implementation of Universal Credit (UC), which combines six existing benefits and tax credits into a single payment for low-income households. Despite extensive reports of hardship associated with the introduction of UC, no previous studies have comprehensively evaluated its impact on mental health. Because payments are targeted at low-income households, impacts on mental health will have important consequences for health inequalities.

METHODS AND ANALYSIS

We will conduct a mixed methods study. Work package (WP) 1 will compare health outcomes for new recipients of UC with outcomes for legacy benefit recipients in two large population surveys, using the phased rollout of UC as a natural experiment. We will also analyse the relationship between the proportion of UC claimants in small areas and a composite measure of mental health. WP2 will use data collected by Citizen's Advice to explore the sociodemographic and health characteristics of people who seek advice when claiming UC and identify features of the claim process that prompt advice-seeking. WP3 will conduct longitudinal in-depth interviews with up to 80 UC claimants in England and Scotland to explore reasons for claiming and experiences of the claim process. Up to 30 staff supporting claimants will also be interviewed. WP4 will use a dynamic microsimulation model to simulate the long-term health impacts of different implementation scenarios. WP5 will undertake cost-consequence analysis of the potential costs and outcomes of introducing UC and cost-benefit analyses of mitigating actions.

ETHICS AND DISSEMINATION

We obtained ethical approval for the primary data gathering from the University of Glasgow, College of Social Sciences Research Ethics Committee, application number 400200244. We will use our networks to actively disseminate findings to UC claimants, the public, practitioners and policy-makers, using a range of methods and formats.

TRIAL REGISTRATION NUMBER

The study is registered with the Research Registry: researchregistry6697.

A review of the effectiveness and experiences of welfare advice services co-located in health settings: A critical narrative systematic review

We conducted a narrative systematic review to assess the health, social and financial impacts of co-located welfare services in the UK and to explore the effectiveness of and facilitators and barriers to successful implementation of these services, in order to guide future policy and practice. We searched Medline, EMBASE and other literature sources, from January 2010 to November 2020, for literature examining the impact of co-located welfare services in the UK on any outcome. The review identified 14 studies employing a range of study designs, including: one non-randomised controlled trial; one pilot randomised controlled trial; one before-and-after-study; three qualitative studies; and eight case studies. A theory of change model, developed a priori, was used as an analytical framework against which to map the evidence on how the services work, why and for whom. All studies demonstrated improved financial security for participants, generating an average of £27 of social, economic and environmental return per £1 invested. Some studies reported improved mental health for individuals accessing services. Several studies attributed subjective improvements in physical health to the service addressing key social determinants of health. Benefits to the health service were also demonstrated through reduced workload for healthcare professionals. Key components of a successful service included co-production during service development and ongoing enhanced multi-disciplinary collaboration. Overall, this review demonstrates improved financial security for participants and for the first time models the wider health and welfare benefits for participants and for health service from these services. However, given the generally poor scientific quality of the studies, care must be taken in drawing firm conclusions. There remains a need for more high quality research, using experimental methods and larger sample sizes, to further build upon this evidence base and to measure the strength of the proposed theoretical pathways in this area.

Mental Health Challenges Related to Neoliberal Capitalism in the United States

Rates of mental illness have increased dramatically over the past 15 years in the United States [Products-Data Briefs-Number 283-August 2017. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db283.htm . Published August 15, 2017]. Additionally, life expectancy has fallen over the past several years due to increases in death from suicide, opioid overdose, and alcoholic liver cirrhosis as reported by Case and Deaton [Deaths of despair and the future of capitalism. Princeton University Press, 2020]. Over the last decade some have questioned whether these changes are due to neoliberal capitalist policies and ideologies. Neoliberal capitalism incorporates theories of eliminating all restrictions on the market and decreasing government assistance programs as reported by Harvey [A brief history of neoliberalism, Oxford University Press, 2005]. Since then these policies have led to income inequality, disempowerment of workers, outsourcing of manufacturing jobs, inadequate social services, mass incarceration and an expensive and ineffective healthcare system as reported by Case and Deaton [Deaths of despair and the future of capitalism. Princeton University Press, 2020] and Nkansah-Amankra et al. [International Journal of Health Services 43(2):217-240, 2013]. Studies have shown that the consequences of these policies and ideologies likely have a role in increasing rates of mental illness. This paper will discuss how these factors increase mental distress and postulate ways that mental health professionals can advocate for change.

Mental Health Challenges Related to Neoliberal Capitalism in the United States

Rates of mental illness have increased dramatically over the past 15 years in the United States [Products-Data Briefs-Number 283-August 2017. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db283.htm . Published August 15, 2017]. Additionally, life expectancy has fallen over the past several years due to increases in death from suicide, opioid overdose, and alcoholic liver cirrhosis as reported by Case and Deaton [Deaths of despair and the future of capitalism. Princeton University Press, 2020]. Over the last decade some have questioned whether these changes are due to neoliberal capitalist policies and ideologies. Neoliberal capitalism incorporates theories of eliminating all restrictions on the market and decreasing government assistance programs as reported by Harvey [A brief history of neoliberalism, Oxford University Press, 2005]. Since then these policies have led to income inequality, disempowerment of workers, outsourcing of manufacturing jobs, inadequate social services, mass incarceration and an expensive and ineffective healthcare system as reported by Case and Deaton [Deaths of despair and the future of capitalism. Princeton University Press, 2020] and Nkansah-Amankra et al. [International Journal of Health Services 43(2):217-240, 2013]. Studies have shown that the consequences of these policies and ideologies likely have a role in increasing rates of mental illness. This paper will discuss how these factors increase mental distress and postulate ways that mental health professionals can advocate for change.

Burden and benefits-related suicides: “misperception” or state crafted reality?

Purpose

This article aims to focus on deaths by suicide in relation to UK welfare reform as a case study to question one of suicidology’s most dominant theories – the Interpersonal Theory of Suicide (Joiner, 2005) and its influential ideas on “perceived burdensomeness” – as well as wider ideologies on suicide and mental health reflected in this approach.

Design/methodology/approach

This article draws on evidence from disabled people’s campaigning groups (primary sources) and research literature (secondary sources), which shows the negative psychological impact of burden discourse and how this shows up in people’s accounts of feeling suicidal, in suicide notes and in family accounts of those who have died by suicide. It uses this evidence to problematise the Interpersonal Theory of Suicide (Joiner, 2005), specifically its ideas about “burden” as an individual misperception, and the assumption that suicide is always the outcome of mental health problems.

Findings

The findings highlight the systemic, intersectional and cumulative production of suicidality by governmental “welfare reform” in the UK, through positioning welfare claimants as “burdens” on society. They show that by locating the problem of burdensomeness in individual “misperceptions”, the Interpersonal Theory allows the government’s role in crafting stigmatisation and conditions of suicidality to be overlooked and to be reproduced.

Originality/value

The article raises urgent ethical questions about the application of approaches, such as the Interpersonal Theory of Suicide, to benefits-related suicides and calls for approaches to benefits-related harm and suicide to be rooted in social and disability justice.

Perspective Commentary: The Implementation of Welfare Policies Are Not Held to the Same Ethical Standards as Research: Raising Intergenerational Health Inequality Concerns

Over the last 12 years the United Kingdom (UK) has seen the introduction of an austerity programme-a fiscal policy-with the primary goal to reduce the government's budget deficit and the role of the welfare system. Between 2010 and 2015 there was an estimated reduction of £14.5 billion in spending, attributable to decreasing the value of benefits and restricting entitlement to benefit claimants. By 2020, there had been an estimated unprecedented £27 billion less spent on welfare compared with spending in 2010. Whilst fiscally-successful at reducing spending, some implemented welfare policies have had direct consequences for people's health, increasing inequalities which have been heavily criticized. Moreover, there is growing concern that this has an intergenerational effect. In this paper, we describe the ethical principles in human research, how these have been considered in public health policy, and the existing evidence of the direct and intergenerational health and welfare consequences of some recent, nationally-implemented welfare policies. We argue that ethical principles, specifically the ethical principle of safety that is applied in all research, should be applied to all public welfare policies to stop the rising inequalities in health we are seeing across generations. We highlight that initial changes implemented to welfare policies as a response to COVID-19 demonstrate that there can be a political and societal perceived value in going further to support individuals and their families during times of adversity, and consider the ethical implications of this.

National or population level interventions addressing the social determinants of mental health - an umbrella review

Background

Social circumstances in which people live and work impact the population’s mental health. We aimed to synthesise evidence identifying effective interventions and policies that influence the social determinants of mental health at national or scaled population level. We searched five databases (Cochrane Library, Global Health, MEDLINE, EMBASE and PsycINFO) between Jan 1st 2000 and July 23rd 2019 to identify systematic reviews of population-level interventions or policies addressing a recognised social determinant of mental health and collected mental health outcomes. There were no restrictions on country, sub-population or age. A narrative overview of results is provided. Quality assessment was conducted using Assessment of Multiple Systematic Reviews (AMSTAR 2). This study was registered on PROSPERO (CRD42019140198).

Results

We identified 20 reviews for inclusion. Most reviews were of low or critically low quality. Primary studies were mostly observational and from higher income settings. Higher quality evidence indicates more generous welfare benefits may reduce socioeconomic inequalities in mental health outcomes. Lower quality evidence suggests unemployment insurance, warm housing interventions, neighbourhood renewal, paid parental leave, gender equality policies, community-based parenting programmes, and less restrictive migration policies are associated with improved mental health outcomes. Low quality evidence suggests restriction of access to lethal means and multi-component suicide prevention programmes are associated with reduced suicide risk.

Conclusion

This umbrella review has identified a small and overall low-quality evidence base for population level interventions addressing the social determinants of mental health. There are significant gaps in the evidence base for key policy areas, which limit ability of national policymakers to understand how to effectively improve population mental health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12145-1.

Local government funding and life expectancy in England: a longitudinal ecological study

Background

Since 2010, large reductions in funding for local government services have been introduced in England. These reductions in funding have potentially led to reduced provision of health-promoting public services. We aimed to investigate whether areas that showed a greater decline in funding also had more adverse trends in life expectancy and premature mortality.

Methods

In this longitudinal ecological study, we linked annual data from the Ministry of Housing, Communities, and Local Government on local government revenue expenditure and financing to 147 upper-tier local authorities in England between 2013 and 2017 with data from Public Health England, on male and female life expectancy at birth, male and female life expectancy at age 65 years, and premature (younger than 75 years) all-cause mortality rate for male and female individuals. Local authorities were excluded if their populations were too small or if changes in boundaries meant consistent data were not available. Using multivariable fixed-effects panel regression models, and controlling for local socioeconomic conditions, we estimated whether changes in local funding from 2013 were associated with changes in life expectancy and premature mortality. We included a set of alternative model specifications to test the robustness of our findings.

Findings

Between 2013 and 2017, mean per-capita central funding to local governments decreased by 33% or £168 per person (range –£385 to £1). Each £100 reduction in annual per person funding was associated over the study period 2013–17 with an average decrease in life expectancy at birth of 1·3 months (95% CI 0·7–1·9) for male individuals and 1·2 months (0·7–1·7) for female individuals; for life expectancy at age 65 years, the results show a decrease of 0·8 months (0·3–1·3) for male individuals and 1·1 months (0·7–1·5) for female individuals. Funding reductions were greater in more deprived areas and these areas had the worst changes in life expectancy. We estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women. Overall reductions in funding during this period were associated with an additional 9600 deaths in people younger than 75 years in England (3800–15 400), an increase of 1·25%.

Interpretation

Our findings indicate that cuts in funding for local government might in part explain adverse trends in life expectancy. Given that more deprived areas showed greater reductions in funding, our analysis suggests that inequalities have widened. Since the pandemic, strategies to address these adverse trends in life expectancy and reduce health inequalities could prioritise reinvestment in funding for local government services, particularly within the most deprived areas of England.

Funding

National Institute for Health Research (NIHR) School for Public Health Research, NIHR Applied Research Collaboration North East and North Cumbria, NIHR Applied Research Collaboration North West Coast and Medical Research Council.

PAID study design on the role of PKC activation in immune/inflammation-related depression: a randomised placebo-controlled trial protocol

Background

Inflammation that is mediated by microglia activation plays an important role in the pathogenesis of depression. Microglia activation can lead to an increase in the levels of proinflammatory cytokines, including TNF-α, which leads to neuronal apoptosis in the specific neural circuits of some brain regions, abnormal cognition and treatment-resistant depression (TRD). Protein kinase C (PKC) is a key regulator of the microglia activation process. We assume that the abnormality in PKC might result in abnormal microglia activation, neuronal apoptosis, significant changes in emotional and cognitive neural circuits, and TRD. In the current study, we plan to target at the PKC signal pathway to improve the TRD treatment outcome.

Methods and analysis

This is a 12-week, ongoing, randomised, placebo-controlled trial. Patients with TRD (N=180) were recruited from Shanghai Mental Health Center, Shanghai Jiao Tong University. Healthy control volunteers (N=60) were recruited by advertisement. Patients with TRD were randomly assigned to 'escitalopram+golimumab (TNF-α inhibitor)', 'escitalopram+calcium tablet+vitamin D (PKC activator)' or 'escitalopram+placebo' groups. We define the primary outcome as changes in the 17-item Hamilton Depression Rating Scale (HAMD-17). The secondary outcome is defined as changes in anti-inflammatory effects, cognitive function and quality of life.

Discussion

This study might be the first randomised, placebo-controlled trial to target at the PKC signal pathway in patients with TRD. Our study might help to propose individualised treatment strategies for depression.

Trial registration number

The trial protocol is registered with ClinicalTrials.gov under protocol ID 81930033 and ClinicalTrials.gov ID NCT04156425.

Why were there 231 707 more deaths than expected in England between 2010 and 2018? An ecological analysis of mortality records

BACKGROUND

Policy responses to the Global Financial Crisis emphasized wide-ranging fiscal austerity measures, many of which have been found to negatively impact health outcomes. This paper investigates change in patterns of mortality at local authority level in England (2010-11 to 2017-18) and the relation with fiscal austerity measures.

METHODS

Data from official local authority administrative records are used to quantify the gap between observed deaths and what was anticipated in the 2010-based subnational population projections. Regression analyses are used to explore the relation between excess deaths, austerity and wider process of population change at local authority level.

RESULTS

We estimate 231 707 total excess deaths, the majority of which occurred since 2014-15 (89%) across the majority of local authorities (91%). Austerity is positively associated with excess deaths. For working age adults, there is a clear gradient to the impact of austerity, whereas for older adults, the impact is more uniform.

CONCLUSIONS

Fiscal austerity policies contributed to an excess of deaths for older people and widened social inequalities for younger populations. These results call for an end to all austerity measures and require further research into areas with the highest total excess deaths as a priority following the COVID-19 pandemic.

Association between mental health and community support in lockdown communities during the COVID-19 pandemic: Evidence from rural China

Governments worldwide have taken unprecedented social distancing and community lockdown measures to halt the COVID-19 epidemic, leaving millions of people restrained in locked-down communities and their mental well-being at risk. This study examines Chinese rural residents' mental health risk under emergency lockdown during the COVID-19 pandemic. It investigates how the environmental, socioeconomic, and behavioral dimensions of community support affect mental health in this emergency context. We also explore whether community support's effectiveness depends on the strictness of lockdown measures implemented and the level of individual perceived COVID-19 infection risk. We collect self-reported mental health risk, community support, and demographics information through a cross-sectional survey of 3892 Chinese rural residents living in small towns and villages. Ordinary least square regressions are employed to estimate the psychological effects of community support. The results suggest that the COVID-19 epidemic and lockdown policies negatively affect psychological well-being, especially for rural females. The capacity for community production has the largest impact on reducing mental health risks, followed by the stability of basic medical services, community cohesion, housing condition, the stability of communications and transportation supply, and the eco-environment. The effectiveness of different community support dimensions depends on the level of lockdown policy implemented and the levels of one's perceived risk of COVID-19 infection. Our study stresses the psychological significance of a healthy living environment, resilient infrastructure and public service system, and community production capacity during the lockdown in rural towns and villages.

Effects of social security policy reforms on mental health and inequalities: A systematic review of observational studies in high-income countries

Evidence increasingly shows that changes to social security policies can affect population mental health. Thus, in the context of rising burden of mental illness, it is of major importance to better understand how expansions and contractions to the social security system may impact on mental health of both adults and children. The aim of this systematic review is to provide a synthesis of observational literature on the effects on mental health and inequalities in mental health of social security reforms. We conducted a systematic review of quantitative observational studies of specific national and regional social security policy changes in high-income countries and summarised the mental health effects of these policies. We searched seven electronic databases, including Medline, PsychInfo, Embase, CINAHL, ASSIA (Proquest), Scopus and Research Papers in Economics from January 1979 to June 2020. We included both objective and subjective mental health and wellbeing measures. The study quality was assessed using the Validity Assessment tool for econometric studies. We identified 13,403 original records, thirty-eight of which were included in the final review. Twenty-one studies evaluated expansionary social security policies and seventeen studies evaluated contractionary policies. Overall, we found that policies that improve social security benefit eligibility/generosity are associated with improvements in mental health, as reported by fourteen of the included studies. Social security policies that reduce eligibility/generosity were related to worse mental health, as reported by eleven studies. Ten studies found no effect for either policies contracting or expanding welfare support. Fourteen studies also evaluated the impact on mental health inequalities and found that contractionary policies tend to increase inequalities whereas expansionary policies have the opposite effect. Changes in social security policies can have significant effects on mental health and health inequalities across different recipient groups. Such health effects should be taken into account when designing future social policy reforms.

Trends in inequalities in Children Looked After in England between 2004 and 2019: a local area ecological analysis

OBJECTIVE

To assess trends in inequalities in Children Looked After (CLA) in England between 2004 and 2019, after controlling for unemployment, a marker of recession and risk factor for child maltreatment.

DESIGN

Longitudinal local area ecological analysis.

SETTING

150 English upper-tier local authorities.

PARTICIPANTS

Children under the age of 18 years.

PRIMARY OUTCOME MEASURE

The annual age-standardised rate of children starting to be looked after (CLA rate) across English local authorities, grouped into quintiles based on their level of income deprivation. Slope indices of inequality were estimated using longitudinal segmented mixed-effects models, controlling for unemployment.

RESULTS

Since 2008, there has been a precipitous rise in CLA rates and a marked widening of inequalities. Unemployment was associated with rising CLA rates: for each percentage point increase in unemployment rate, an estimated additional 9 children per 100 000 per year (95% CI 6 to 11) became looked after the following year. However, inequalities increased independently of the effect of unemployment. Between 2007 and 2019, after controlling for unemployment, the gap between the most and least deprived areas increased by 15 children per 100 000 per year (95% CI 4 to 26) relative to the 2004-2006 trend.

CONCLUSIONS

The dramatic increase in the rate of children starting to be looked after has been greater in poorer areas and in areas more deeply affected by recession. But trends in unemployment do not explain the decade-long rise in inequalities, suggesting that other socioeconomic factors, including rising child poverty and reduced spending on children's services, may be fuelling inequalities. Policies to safely reduce the CLA rate should urgently address the social determinants of child health and well-being.

The contribution of changes to tax and social security to stalled life expectancy trends in Scotland: a modelling study

BACKGROUND

Life expectancy (LE) improvements have stalled, and UK tax and welfare 'reforms' have been proposed as a cause. We estimated the effects of tax and welfare reforms from 2010/2011 to 2021/2022 on LE and inequalities in LE in Scotland.

METHODS

We applied a published estimate of the cumulative income impact of the reforms to the households within Scottish Index of Multiple Deprivation (SIMD) quintiles. We estimated the impact on LE by applying a rate ratio for the impact of income on mortality rates (by age group, sex and SIMD quintile) and calculating the difference between inflation-only changes in benefits and the reforms.

RESULTS

We estimated that changes to household income resulting from the reforms would result in an additional 1041 (+3.7%) female deaths and 1013 (+3.8%) male deaths. These deaths represent an estimated reduction of female LE from 81.6 years to 81.2 years (-20 weeks), and male LE from 77.6 years to 77.2 years (-23 weeks). Cuts to benefits and tax credits were modelled to have the most detrimental impact on LE, and these were estimated to be most severe in the most deprived areas. The modelled impact on inequalities in LE was widening of the gap between the most and least deprived 20% of areas by a further 21 weeks for females and 23 weeks for males.

INTERPRETATION

This study provides further evidence that austerity, in the form of cuts to social security benefits, is likely to be an important cause of stalled LE across the UK.

A qualitative investigation of lived experiences of long-term health condition management with people who are food insecure

Background

As more people are living with one or more chronic health conditions, supporting patients to become activated, self-managers of their conditions has become a key health policy focus both in the UK and internationally. There is also growing evidence in the UK that those with long term health conditions have an increased risk of being food insecure. While international evidence indicates that food insecurity adversely affects individual’s health condition management capability, little is known about how those so affected manage their condition(s) in this context. An investigation of lived experience of health condition management was undertaken with food insecure people living in north east Scotland. The study aimed to explore the challenges facing food insecure people in terms of, i. their self-care condition management practices, and ii. disclosing and discussing the experience of managing their condition with a health care professional, and iii. Notions of the support they might wish to receive from them.

Methods

Twenty in-depth interviews were conducted with individuals attending a food bank and food pantry in north east Scotland. Interview audio recordings were fully transcribed and thematically analysed.

Results

Individuals reporting multiple physical and mental health conditions, took part in the study. Four main themes were identified i.e.: 1. food practices, trade-offs and compromises, that relate to economic constraints and lack of choice; 2. illness experiences and food as they relate to physical and mental ill-health; 3. (in) visibility of participants’ economic vulnerability within health care consultations; and 4. perceptions and expectations of the health care system.

Conclusions

This study, the first of its kind in the UK, indicated that participants’ health condition management aspirations were undermined by the experience of food insecurity, and that their health care consultations in were, on the whole, devoid of discussions of those challenges. As such, the study indicated practical and ethical implications for health care policy, practice and research associated with the risk of intervention-generated health inequalities that were suggested by this study. Better understanding is needed about the impact of household food insecurity on existing ill health, wellbeing and health care use across the UK.

Predicting return to work after long-term sickness absence with subjective health complaints: a prospective cohort study

BACKGROUND

Long-term sickness absence results in increased risks of permanent disability and a compromised quality of life. Return to work is an important factor in reducing these risks. Little is known about return to work factors for long-term sick-listed workers with subjective health complaints. The aim of this study was to evaluate prognostic factors for partial or full return to a paid job for at least 28 days for long-term sick-listed workers with subjective health complaints, and to compare these factors with those of workers with other disorders.

METHODS

Data from a prospective cohort study of 213 participants with subjective health complaints and 1.037 reference participants were used. The participants answered a questionnaire after 84 weeks of sickness absence. Return to work was measured after one and two years. Univariable logistic regression analyses were performed (P ≤ 0.157) for variables per domain with return to work (i.e. demographic, socio-economic and work-related, health-related, and self-perceived ability). Subsequently, multivariable logistic regression analyses with backward selection (P ≤ 0.157) were performed. Remaining factors were combined in a multivariable and final model (P ≤ 0.05).

RESULTS

Both for workers with subjective health complaints and for the reference group, non-health-related factors remained statistically significant in the final model. This included receiving a partial or complete work disability benefit (partial: OR 0.62, 95% CI 0.26-1.47 and OR 0.69, 95% CI 0.43-1.12; complete: OR 0.24, 95% CI 0.10-0.58 and OR 0.12, 95% CI 0.07-0.20) and having a positive self-perceived possibility for return to work (OR 1.06, 95% CI 1.01-1.11 and OR 1.08, 95% CI 1.05-1.11).

CONCLUSIONS

Non-health-related factors seem to be more important than health-related factors in predicting return to work after long-term sickness absence. Receiving a work disability benefit and having negative expectations for return to work seem to complicate return to work most for workers with subjective health complaints. With respect to return to work predictors, workers with subjective health complaints do not differ from the reference group.