Evaluating the influence of taxation and social security policies on psychological distress: A microsimulation study of the UK during the COVID-19 economic crisis

Economic determinants are important for population health, but actionable evidence of how policies can utilise these pathways remains scarce. This study employs a microsimulation framework to evaluate the effects of taxation and social security policies on population mental health. The UK economic crisis caused by the COVID-19 pandemic provides an informative context involving an economic shock accompanied by one of the strongest discretionary fiscal responses amongst OECD countries. The analytical setup involves a dynamic, stochastic, discrete-time microsimulation model (SimPaths) projecting changes in psychological distress given predicted economic outcomes from a static tax-benefit microsimulation model (UKMOD) based on different policy scenarios. We contrast projections of psychological distress for the working-age population from 2017 to 2025 given the observed policy environment against a counterfactual scenario where pre-crisis policies remained in place. Levels of psychological distress and potential cases of common mental disorders (CMDs) were assessed with the 12-item General Health Questionnaire (GHQ-12). The UK policy response to the economic crisis is estimated to have prevented a substantial fall (over 12 percentage points, %pt) in the employment rate in 2020 and 2021. In 2020, projected psychological distress increased substantially (CMD prevalence increase >10%pt) under both the observed and the counterfactual policy scenarios. Through economic pathways, the policy response is estimated to have prevented a further 3.4%pt [95%UI 2.8%pt, 4.0%pt] increase in the prevalence of CMDs, approximately 1.2 million cases. Beyond 2021, as employment levels rapidly recovered, psychological distress returned to the pre-pandemic trend. Sustained preventative effects on poverty are estimated, with projected levels 2.1%pt [95%UI 1.8%pt, 2.5%pt] lower in 2025 than in the absence of the observed policy response. The study shows that policies protecting employment during an economic crisis are effective in preventing short-term mental health losses and have lasting effects on poverty levels. This preventative effect has substantial public health benefits.

A preoperative package of care for osteoarthritis, consisting of weight loss, orthotics, rehabilitation, and topical and oral analgesia (OPPORTUNITY): a two-centre, open-label, randomised controlled feasibility trial

BACKGROUND

Osteoarthritis of the knee is a major cause of disability worldwide. Non-operative treatments can reduce the morbidity but adherence is poor. We hypothesised that adherence could be optimised if behavioural change was established in the preoperative period. Therefore, we aimed to assess feasibility, acceptability, and recruitment and retention rates of a preoperative package of non-operative care in patients awaiting knee replacement surgery.

METHODS

We did an open-label, randomised controlled, feasibility trial in two secondary care centres in the UK. Eligible participants were aged 15-85 years, on the waiting list for a knee arthroplasty for osteoarthritis, and met at least one of the thresholds for one of the four components of the preoperative package of non-operative care intervention (ie, weight loss, exercise therapy, use of insoles, and analgesia adjustment). Participants were randomly assigned (2:1) to either the intervention group or the standard of care (ie, control) group. All four aspects of the intervention were delivered weekly over 12 weeks. Participants in the intervention group were reviewed regularly to assess adherence. The primary outcome was acceptability and feasibility of delivering the intervention, as measured by recruitment rate, retention rate at follow-up review after planned surgery, health-related quality of life, joint-specific scores, and adherence (weight change and qualitative interviews). This study is registered with ISRCTN, ISRCTN96684272.

FINDINGS

Between Sept 3 2018, and Aug 30, 2019, we screened 233 patients, of whom 163 (73%) were excluded and 60 (27%) were randomly assigned to either the intervention group (n=40) or the control group (n=20). 34 (57%) of 60 participants were women, 26 (43%) were men, and the mean age was 66·8 years (SD 8·6). Uptake of the specific intervention components varied: 31 (78%) of 40 had exercise therapy, 28 (70%) weight loss, 22 (55%) analgesia adjustment, and insoles (18 [45%]). Overall median adherence was 94% (IQR 79·5-100). At the final review, the intervention group lost a mean of 11·2 kg (SD 5·6) compared with 1·3 kg (3·8) in the control group (estimated difference -9·8 kg [95% CI -13·4 to -6·3]). A clinically significant improvement in health-related quality o life (mean change 0·078 [SD 0·195]) were reported, and joint-specific scores showed greater improvement in the intervention group than in the control group. No adverse events attributable to the intervention occurred.

INTERPRETATION

Participants adhered well to the non-operative interventions and their health-related quality of life improved. Participant and health professional feedback were extremely positive. These findings support progression to a full-scale effectiveness trial.

FUNDING

Versus Arthritis.

Climate warming shifts riverine macroinvertebrate communities to be more sensitive to chemical pollutants

Freshwaters are highly threatened ecosystems that are vulnerable to chemical pollution and climate change. Freshwater taxa vary in their sensitivity to chemicals and changes in species composition can potentially affect the sensitivity of assemblages to chemical exposure. Here we explore the potential consequences of future climate change on the composition and sensitivity of freshwater macroinvertebrate assemblages to chemical stressors using the UK as a case study. Macroinvertebrate assemblages under end of century (2080-2100) and baseline (1980-2000) climate conditions were predicted for 608 UK sites for four climate scenarios corresponding to mean temperature changes of 1.28 to 3.78°C. Freshwater macroinvertebrate toxicity data were collated for 19 chemicals and the hierarchical species sensitivity distribution model was used to predict the sensitivity of untested taxa using relatedness within a Bayesian approach. All four future climate scenarios shifted assemblage compositions, increasing the prevalence of Mollusca, Crustacea and Oligochaeta species, and the insect taxa of Odonata, Chironomidae, and Baetidae species. Contrastingly, decreases were projected for Plecoptera, Ephemeroptera (except for Baetidae) and Coleoptera species. Shifts in taxonomic composition were associated with changes in the percentage of species at risk from chemical exposure. For the 3.78°C climate scenario, 76% of all assemblages became more sensitive to chemicals and for 18 of the 19 chemicals, the percentage of species at risk increased. Climate warming-induced increases in sensitivity were greatest for assemblages exposed to metals and were dependent on baseline assemblage composition, which varied spatially. Climate warming is predicted to result in changes in the use, environmental exposure and toxicity of chemicals. Here we show that, even in the absence of these climate-chemical interactions, shifts in species composition due to climate warming will increase chemical risk and that the impact of chemical pollution on freshwater macroinvertebrate biodiversity may double or quadruple by the end of the 21st century.

Introducing the revised framework for developing and evaluating complex interventions: A challenge and a resource for nursing research

This invited discussion paper highlights key updates in the MRC/NIHR's revised framework for the development and evaluation of complex nursing interventions and reflects on the implications for nursing research.

Reporting of equity in observational epidemiology: A methodological review

Background

Observational studies can inform how we understand and address persisting health inequities through the collection, reporting and analysis of health equity factors. However, the extent to which the analysis and reporting of equity-relevant aspects in observational research are generally unknown. Thus, we aimed to systematically evaluate how equity-relevant observational studies reported equity considerations in the study design and analyses.

Methods

We searched MEDLINE for health equity-relevant observational studies from January 2020 to March 2022, resulting in 16 828 articles. We randomly selected 320 studies, ensuring a balance in focus on populations experiencing inequities, country income settings, and coronavirus disease 2019 (COVID-19) topic. We extracted information on study design and analysis methods.

Results

The bulk of the studies were conducted in North America (n = 95, 30%), followed by Europe and Central Asia (n = 55, 17%). Half of the studies (n = 171, 53%) addressed general health and well-being, while 49 (15%) focused on mental health conditions. Two-thirds of the studies (n = 220, 69%) were cross-sectional. Eight (3%) engaged with populations experiencing inequities, while 22 (29%) adapted recruitment methods to reach these populations. Further, 67 studies (21%) examined interaction effects primarily related to race or ethnicity (48%). Two-thirds of the studies (72%) adjusted for characteristics associated with inequities, and 18 studies (6%) used flow diagrams to depict how populations experiencing inequities progressed throughout the studies.

Conclusions

Despite over 80% of the equity-focused observational studies providing a rationale for a focus on health equity, reporting of study design features relevant to health equity ranged from 0-95%, with over half of the items reported by less than one-quarter of studies. This methodological study is a baseline assessment to inform the development of an equity-focussed reporting guideline for observational studies as an extension of the well-known Strengthening Reporting of Observational Studies in Epidemiology (STROBE) guideline.

Reprint of: 'A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance'

The UK Medical Research Council's widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.

Evaluation of the Healthy Start voucher scheme on maternal vitamin use and child breastfeeding: a natural experiment using data linkage

Background

Having a good start in life during pregnancy and infancy has been shown to be important for living both a healthy life and a longer life. Despite the introduction of many policies for the early-years age group, including voucher schemes, with the aim of improving nutrition, there is limited evidence of their impact on health.

Objectives

To assess the effectiveness of the Healthy Start voucher scheme on infant, child and maternal outcomes, and to capture the lived experiences of the Healthy Start voucher scheme for low-income women.

Design

This was a natural experiment study using existing data sets, linked to routinely collected health data sets, with a nested qualitative study of low-income women and an assessment of the health economics.

Setting

Representative sample of Scottish children and UK children.

Participants

Growing Up in Scotland cohort 2 (n = 2240), respondents to the 2015 Infant Feeding Study (n = 8067) and a sample of 40 participants in the qualitative study.

Interventions

The Health Start voucher, a means-tested scheme that provides vouchers worth £3.10 per week to spend on liquid milk, formula milk, fruit and vegetables.

Main outcome measures

Infant and child outcomes - breastfeeding initiation and duration; maternal outcomes - vitamin use pre and during pregnancy.

Results

The exposed group were women receiving the Healthy Start voucher (R), with two control groups: eligible and not claiming the Healthy Start voucher (E) and nearly eligible. There was no difference in vitamin use during pregnancy for either comparison (receiving the Healthy Start voucher, 82%; eligible and not claiming the Healthy Start voucher, 86%; p = 0.10 vs. receiving the Healthy Start voucher, 87%; nearly eligible, 88%; p = 0.43) in the Growing Up in Scotland cohort. Proportions were similar for the Infant Feeding Study cohort (receiving the Healthy Start voucher, 89%; eligible and not claiming the Healthy Start voucher, 86%; p = 0.01 vs. receiving the Healthy Start voucher, 89%; nearly eligible, 87%; p = 0.01); although results were statistically significantly different, these were small effect sizes. There was no difference for either comparison in breastfeeding initiation or breastfeeding duration in months in Growing Up in Scotland, but there was a negative effect of the Healthy Start voucher in the Infant Feeding Survey. This contrast between data sets indicates that results are inconclusive for breastfeeding. The qualitative study found that despite the low monetary value the women valued the Healthy Start voucher scheme. However, the broader lives of low-income women are crucial to understand the constraints to offer a healthy diet.

Limitations

Owing to the policy being in place, it was difficult to identify appropriate control groups using existing data sources, especially in the Infant Feeding Study.

Conclusions

As the Healthy Start voucher scheme attempts to influence health behaviour, this evaluation can inform other policies aiming to change behaviour and use voucher incentives. The null effect of Healthy Start vouchers on the primary outcomes may be due to the value of the vouchers being insufficient to change the broader lives of low-income women to offer a healthy diet.

Future work

The methods developed to undertake an economic evaluation alongside a natural experiment using existing data can be used to explore the cost-effectiveness of the Healthy Start voucher scheme.

Funding

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

Implementation of a national smoke-free prison policy: an economic evaluation within the Tobacco in Prisons (TIPs) study

OBJECTIVE

To determine the cost-effectiveness of a smoke-free prison policy in Scotland, through assessments of the trade-offs between costs (healthcare and non-healthcare-related expenditure) and outcomes (health and non-health-related non-monetary consequences) of implementing the policy.

DESIGN

A health economic evaluation consisting of three analyses (cost-consequence, cost-effectiveness and cost-utility), from the perspectives of the healthcare payer, prison service, people in custody and operational staff, assessed the trade-offs between costs and outcomes. Costs associated with the implementation of the policy, healthcare resource use and personal spend on nicotine products were considered, alongside health and non-health outcomes. The cost-effectiveness of the policy was evaluated over 12-month and lifetime horizons (short term and long term).

SETTING

Scotland's national prison estate.

PARTICIPANTS

People in custody and operational prison staff.

INTERVENTION

Implementation of a comprehensive (indoor and outdoor) smoke-free policy.

MAIN OUTCOME MEASURES

Concentration of secondhand smoke, health-related quality of life (health utilities and quality-adjusted life-years (QALY)) and various non-health outcomes (eg, incidents of assaults and fires).

RESULTS

The short-term analyses suggest cost savings for people in custody and staff, improvements in concentration of secondhand smoke, with no consistent direction of change across other outcomes. The long-term analysis demonstrated that implementing smoke-free policy was cost-effective over a lifetime for people in custody and staff, with approximate cost savings of £28 000 and £450, respectively, and improvement in health-related quality of life of 0.971 QALYs and 0.262, respectively.

CONCLUSION

Implementing a smoke-free prison policy is cost-effective over the short term and long term for people in custody and staff.

A scoping review establishes need for consensus guidance on reporting health equity in observational studies

OBJECTIVES

To evaluate the support from the available guidance on reporting of health equity in research for our candidate items and to identify additional items for the Strengthening Reporting of Observational studies in Epidemiology-Equity extension.

STUDY DESIGN AND SETTING

We conducted a scoping review by searching Embase, MEDLINE, CINAHL, Cochrane Methodology Register, LILACS, and Caribbean Center on Health Sciences Information up to January 2022. We also searched reference lists and gray literature for additional resources. We included guidance and assessments (hereafter termed "resources") related to conduct and/or reporting for any type of health research with or about people experiencing health inequity.

RESULTS

We included 34 resources, which supported one or more candidate items or contributed to new items about health equity reporting in observational research. Each candidate item was supported by a median of six (range: 1-15) resources. In addition, 12 resources suggested 13 new items, such as "report the background of investigators".

CONCLUSION

Existing resources for reporting health equity in observational studies aligned with our interim checklist of candidate items. We also identified additional items that will be considered in the development of a consensus-based and evidence-based guideline for reporting health equity in observational studies.

The health impact of Scotland's Baby Box Scheme: a natural experiment evaluation using national linked health data

BACKGROUND

Scotland's Baby Box Scheme (SBBS) is a national programme offering a box of essential items to all pregnant women in Scotland intended to improve infant and maternal health. We aimed to evaluate the effect of SBBS on selected infant and maternal health outcomes at population and subgroup levels (maternal age and area deprivation).

METHODS

Our complete-case, intention-to-treat evaluation used national health data (from the Scottish Morbidity Record [SMR] 01, SMR02, and the Child Health Surveillance Programme-Pre School), linking birth records to postnatal hospitalisation and universal health visitor records in Scotland. We considered maternal-infant pairs of all live-singleton births 2 years either side of SBBS introduction (Aug 17, 2015, to Aug 11, 2019). We estimated step-changes and trend-changes in outcomes (hospital admission and self-reported exclusive breastfeeding, tobacco smoke exposure, and infant sleeping position) by week of birth using segmented Poisson regression, adjusting for over-dispersion and seasonality where necessary.

FINDINGS

The analysis comprised 182 122 maternal-infant pairs. The prevalence of tobacco smoke exposure reduced after SBBS introduction: step decrease of 10% (prevalence ratio 0·904 [95% CI 0·865-0·946]; absolute decrease of 1·6% 1 month post-introduction) for infants and 9% (0·905 [0·862-0·950]; absolute decrease of 1·9% 1 month post-introduction) for the primary carer. There was no evidence of changes in infant and maternal all-cause hospital admissions or infant sleeping position. Among mothers younger than 25 years, there was a 10% step-increase in breastfeeding prevalence (1·095 [1·004-1·195]; absolute increase of 2·2% 1 month post-introduction) at 10 days and 17% (1·174 [1·037-1·328]) at 6-8 weeks postnatal. Although associations were robust to most sensitivity analyses, for smoke exposure associations were only observed early in the postnatal period.

INTERPRETATION

SBBS reduced infant and primary carer tobacco smoke exposure, and increased breastfeeding among young mothers in Scotland. However, absolute effects were small.

FUNDING

Medical Research Council, Scottish Government Chief Scientist Office, and National Records of Scotland.

Natural experiments for the evaluation of place-based public health interventions: a methodology scoping review

Introduction

Place-based public health evaluations are increasingly making use of natural experiments. This scoping review aimed to provide an overview of the design and use of natural experiment evaluations (NEEs), and an assessment of the plausibility of the as-if randomization assumption.

Methods

A systematic search of three bibliographic databases (Pubmed, Web of Science and Ovid-Medline) was conducted in January 2020 to capture publications that reported a natural experiment of a place-based public health intervention or outcome. For each, study design elements were extracted. An additional evaluation of as-if randomization was conducted by 12 of this paper's authors who evaluated the same set of 20 randomly selected studies and assessed 'as-if ' randomization for each.

Results

366 NEE studies of place-based public health interventions were identified. The most commonly used NEE approach was a Difference-in-Differences study design (25%), followed by before-after studies (23%) and regression analysis studies. 42% of NEEs had likely or probable as-if randomization of exposure (the intervention), while for 25% this was implausible. An inter-rater agreement exercise indicated poor reliability of as-if randomization assignment. Only about half of NEEs reported some form of sensitivity or falsification analysis to support inferences.

Conclusion

NEEs are conducted using many different designs and statistical methods and encompass various definitions of a natural experiment, while it is questionable whether all evaluations reported as natural experiments should be considered as such. The likelihood of as-if randomization should be specifically reported, and primary analyses should be supported by sensitivity analyses and/or falsification tests. Transparent reporting of NEE designs and evaluation methods will contribute to the optimum use of place-based NEEs.

Understanding inequalities in mental health by family structure during COVID-19 lockdowns: evidence from the UK Household Longitudinal Study

PURPOSE

The COVID-19 pandemic increased psychiatric distress and impacts differed by family structure. We aimed to identify mechanisms contributing to these inequalities.

METHODS

Survey data were from the UK Household Longitudinal Study. Psychiatric distress (GHQ-12) was measured in April 2020 (first UK lockdown; n = 10,516), and January 2021 (lockdown re-introduced following eased restrictions; n = 6,893). Pre-lockdown family structure comprised partner status and presence of children (< 16 years). Mediating mechanisms included: active employment, financial strain, childcare/home-schooling, caring, and loneliness. Monte Carlo g-computation simulations were used to adjust for confounding and estimate total effects and decompositions into: controlled direct effects (effects if the mediator was absent), and portions eliminated (PE; representing differential exposure and vulnerability to the mediator).

RESULTS

In January 2021, after adjustment, we estimated increased risk of distress among couples with children compared to couples with no children (RR: 1.48; 95% CI 1.15-1.82), largely because of childcare/home-schooling (PE RR: 1.32; 95% CI 1.00-1.64). Single respondents without children also had increased risk of distress compared to couples with no children (RR: 1.55; 95% CI 1.27-1.83), and the largest PE was for loneliness (RR: 1.16; 95% CI 1.05-1.27), though financial strain contributed (RR: 1.05; 95% CI 0.99-1.12). Single parents demonstrated the highest levels of distress, but confounder adjustment suggested uncertain effects with wide confidence intervals. Findings were similar in April 2020 and when stratified by sex.

CONCLUSION

Access to childcare/schooling, financial security and social connection are important mechanisms that need addressing to avoid widening mental health inequalities during public health crises.

Subsidised housing and diabetes mortality: a retrospective cohort study of 10 million low-income adults in Brazil

INTRODUCTION

Housing-related factors can be predictors of health, including of diabetes outcomes. We analysed the association between subsidised housing residency and diabetes mortality among a large cohort of low-income adults in Brazil.

RESEARCH DESIGN AND METHODS

A cohort of 9 961 271 low-income adults, observed from January 2010 to December 2015, was created from Brazilian administrative records of social programmes and death certificates. We analysed the association between subsidised housing residency and time to diabetes mortality using a Cox model with inverse probability of treatment weighting and regression adjustment. We assessed inequalities in this association by groups of municipality Human Development Index. Diabetes mortality included diabetes both as the underlying or a contributory cause of death.

RESULTS

At baseline, the mean age of the cohort was 40.3 years (SD 15.6 years), with a majority of women (58.4%). During 29 238 920 person-years of follow-up, there were 18 775 deaths with diabetes as the underlying or a contributory cause. 340 683 participants (3.4% of the cohort) received subsidised housing. Subsidised housing residents had a higher hazard of diabetes mortality compared with non-residents (HR 1.17; 95% CI 1.05 to 1.31). The magnitude of this association was more pronounced among participants living in municipalities with lower Human Development Index (HR 1.30; 95% CI 1.04 to 1.62).

CONCLUSIONS

Subsidised housing residents had a greater risk of diabetes mortality, particularly those living in low socioeconomic status municipalities. This finding suggests the need to intensify diabetes prevention and control actions and prompt treatment of the diabetes complications among subsidised housing residents, particularly among those living in low socioeconomic status municipalities.

Improving social justice in observational studies: protocol for the development of a global and Indigenous STROBE-equity reporting guideline

BACKGROUND

Addressing persistent and pervasive health inequities is a global moral imperative, which has been highlighted and magnified by the societal and health impacts of the COVID-19 pandemic. Observational studies can aid our understanding of the impact of health and structural oppression based on the intersection of gender, race, ethnicity, age and other factors, as they frequently collect this data. However, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, does not provide guidance related to reporting of health equity. The goal of this project is to develop a STROBE-Equity reporting guideline extension.

METHODS

We assembled a diverse team across multiple domains, including gender, age, ethnicity, Indigenous background, disciplines, geographies, lived experience of health inequity and decision-making organizations. Using an inclusive, integrated knowledge translation approach, we will implement a five-phase plan which will include: (1) assessing the reporting of health equity in published observational studies, (2) seeking wide international feedback on items to improve reporting of health equity, (3) establishing consensus amongst knowledge users and researchers, (4) evaluating in partnership with Indigenous contributors the relevance to Indigenous peoples who have globally experienced the oppressive legacy of colonization, and (5) widely disseminating and seeking endorsement from relevant knowledge users. We will seek input from external collaborators using social media, mailing lists and other communication channels.

DISCUSSION

Achieving global imperatives such as the Sustainable Development Goals (e.g., SDG 10 Reduced inequalities, SDG 3 Good health and wellbeing) requires advancing health equity in research. The implementation of the STROBE-Equity guidelines will enable a better awareness and understanding of health inequities through better reporting. We will broadly disseminate the reporting guideline with tools to enable adoption and use by journal editors, authors, and funding agencies, using diverse strategies tailored to specific audiences.

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.

Impact of the Finnish Maternity Grant on infant mortality rates in the 20th century: a natural experimental study

BACKGROUND

Baby boxes provide goods to new parents and a space for infant sleeping. They were first introduced in Finland, and it has been argued that the policy helped reduce infant mortality. We evaluated the impact of the Finnish Maternity Grant (which includes the Finnish Baby Box) on infant mortality rates (IMRs) at the points of introduction (disadvantaged mothers only) in 1938 and universalisation in 1949.

METHODS

Maternity Grant introduction and universalisation were evaluated as distinct natural experimental events, using interrupted time series analysis. The outcome was IMR per 1000 live births. We analysed national data on all infants born in Finland between 1922 and 1975, estimating step and trend changes in the outcome following the point of intervention. Sensitivity analyses included truncating the pre-intervention period and a double break point model, incorporating terms for both introduction and universalisation.

RESULTS

Maternity grant introduction in 1938 was associated with a step-change increase (β=14.59, 95% CI 4.30 to 24.89) in Finnish IMRs. Maternity grant universalisation in 1949 was associated with a step-change decrease (β=-14.35, 95% CI -20.94 to -7.76) in Finnish IMRs. Sensitivity analyses produced corresponding associations.

CONCLUSIONS

While we observed changes in IMRs associated with Maternity Grant introduction and universalisation, these changes cannot be disentangled from the impact of the Second World War or other relevant policy developments on infant mortality. Consequently, the relationship between the Finnish Baby Box or comparable contemporary interventions and infant mortality remains unclear.

Impact of Brazil's Bolsa Família Programme on cardiovascular and all-cause mortality: a natural experiment study using the 100 Million Brazilian Cohort

BACKGROUND

Cardiovascular disease (CVD) has a disproportionate effect on mortality among the poorest people. We assessed the impact on CVD and all-cause mortality of the world's largest conditional cash transfer, Brazil's Bolsa Família Programme (BFP).

METHODS

We linked administrative data from the 100 Million Brazilian Cohort with BFP receipt and national mortality data. We followed individuals who applied for BFP between 1 January 2011 and 31 December 2015, until 31 December 2015. We used marginal structural models to estimate the effect of BFP on all-age and premature (30-69 years) CVD and all-cause mortality. We conducted stratified analyses by levels of material deprivation and access to healthcare. We checked the robustness of our findings by restricting the analysis to municipalities with better mortality data and by using alternative statistical methods.

RESULTS

We studied 17 981 582 individuals, of whom 4 855 324 were aged 30-69 years. Three-quarters (76.2%) received BFP, with a mean follow-up post-award of 2.6 years. We detected 106 807 deaths by all causes, of which 60 893 were premature; and 23 389 CVD deaths, of which 15 292 were premature. BFP was associated with reductions in premature all-cause mortality [hazard ratio (HR) = 0.96, 95% CI = 0.94-0.98], premature CVD (HR = 0.96, 95% CI = 0.92-1.00) and all-age CVD (HR = 0.96, 95% CI = 0.93-1.00) but not all-age all-cause mortality (HR = 1.00, 95% CI = 0.98-1.02). In stratified and robustness analyses, BFP was consistently associated with mortality reductions for individuals living in the two most deprived quintiles.

CONCLUSIONS

BFP appears to have a small to null effect on premature CVD and all-cause mortality in the short term; the long-term impact remains unknown.

Causal inference and effect estimation using observational data

Observational studies aiming to estimate causal effects often rely on conceptual frameworks that are unfamiliar to many researchers and practitioners. We provide a clear, structured overview of key concepts and terms, intended as a starting point for readers unfamiliar with the causal inference literature. First, we introduce theoretical frameworks underlying causal effect estimation methods: the counterfactual theory of causation, the potential outcomes framework, structural equations and directed acyclic graphs. Second, we define the most common causal effect estimands, and the issues of effect measure modification, interaction and mediation (direct and indirect effects). Third, we define the assumptions required to estimate causal effects: exchangeability, positivity, consistency and non-interference. Fourth, we define and explain biases that arise when attempting to estimate causal effects, including confounding, collider bias, selection bias and measurement bias. Finally, we describe common methods and study designs for causal effect estimation, including covariate adjustment, G-methods and natural experiment methods.

Reporting of health equity considerations in equity-relevant observational studies: Protocol for a systematic assessment

Background: The mitigation of unfair and avoidable differences in health is an increasing global priority. Observational studies including cohort, cross-sectional and case-control studies tend to report social determinants of health which could inform evidence syntheses on health equity and social justice. However, the extent of reporting and analysis of equity in equity-relevant observational studies is unknown. Methods: We define studies which report outcomes for populations at risk of experiencing inequities as “equity-relevant”. Using a random sampling technique we will identify 320 equity-relevant observational studies published between 1 January 2020 to 27 April 2022 by searching the MEDLINE database. We will stratify sampling by 1) studies in high-income countries (HIC) and low- and middle-income countries (LMIC) according to the World Bank classification, 2) studies focused on COVID and those which are not, 3) studies focused on populations at risk of experiencing inequities and those on general populations that stratify their analyses. We will use the PROGRESS framework which stands for place of residence, race or ethnicity, occupation, gender or sex, religion, education, socioeconomic status, social capital, to identify dimensions where inequities may exist. Using a previously developed data extraction form we will pilot-test on eligible studies and revise as applicable. Conclusions: The proposed methodological assessment of reporting will allow us to systematically understand the current reporting and analysis practices for health equity in observational studies. The findings of this study will help inform the development of the equity extension for the STROBE (Strengthening the Reporting of Observational studies in Epidemiology) reporting guidelines.

Comparing population-level mental health of UK workers before and during the COVID-19 pandemic: a longitudinal study using Understanding Society

OBJECTIVES

The COVID-19 pandemic has substantially affected workers' mental health. We investigated changes in UK workers' mental health by industry, socioeconomic class and occupation and differential effects by UK country of residence, gender and age.

METHODS

We used representative Understanding Society data from 6474 adults (41 207 observations) in paid employment who participated in pre-pandemic (2017-2020) and at least one COVID-19 survey. The outcome was General Health Questionnaire-12 (GHQ-12) caseness (score: ≥4). Exposures were industry, socioeconomic class and occupation and are examined separately. Mixed-effects logistic regression was used to estimate relative (OR) and absolute (%) increases in distress before and during pandemic. Differential effects were investigated for UK countries of residence (non-England/England), gender (male/female) and age (younger/older) using three-way interaction effects.

RESULTS

GHQ-12 caseness increased in relative terms most for 'professional, scientific and technical' (OR: 3.15, 95% CI 2.17 to 4.59) industry in the pandemic versus pre-pandemic period. Absolute risk increased most in 'hospitality' (+11.4%). For socioeconomic class, 'small employers/self-employed' were most affected in relative and absolute terms (OR: 3.24, 95% CI 2.28 to 4.63; +10.3%). Across occupations, 'sales and customer service' (OR: 3.01, 95% CI 1.61 to 5.62; +10.7%) had the greatest increase. Analysis with three-way interactions showed considerable gender differences, while for UK country of residence and age results are mixed.

CONCLUSIONS

GHQ-12 caseness increases during the pandemic were concentrated among 'professional and technical' and 'hospitality' industries and 'small employers/self-employed' and 'sales and customers service' workers. Female workers often exhibited greater differences in risk by industry and occupation. Policies supporting these industries and groups are needed.

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.

The effect of school summer holidays on inequalities in children and young people's mental health and cognitive ability in the UK using data from the millennium cohort study

BACKGROUND

Summer learning loss has been the subject of longstanding concern among researchers, the public and policy makers. The aim of the current research was to investigate inequality changes in children's mental health and cognitive ability across the summer holidays.

METHODS

We conducted linear and logistic regression analysis of mental health (borderline-abnormal total difficulty and prosocial scores on the strengths and difficulties questionnaire (SDQ)) and verbal cognitive ability (reading, verbal reasoning or vocabulary) at ages 7, 11 and 14, comparing UK Millennium Cohort Study members who were interviewed before and after the school summer holidays. Inequalities were assessed by including interaction terms in the outcome models between a discrete binary variable with values representing time periods and maternal academic qualifications. Coefficients of the interaction terms were interpreted as changes from the pre- to post-holiday period in the extent of inequality in the outcome between participants whose mothers had high or low educational qualifications. Separate models were fitted for each age group and outcome. We used inverse probability weights to allow for differences in the characteristics of cohort members assessed before and after the summer holidays.

RESULTS

Mental health (borderline/abnormal SDQ total and prosocial scores) at ages 7 and 14 worsened and verbal cognitive ability scores at age 7 were lower among those surveyed after the summer holidays. Mental health inequalities were larger after the holidays at age 7 ([OR = 1.4; 95%CI (0.6, 3.2) and 14: [OR = 1.5; 95%CI (0.7, 3.2)], but changed little at age 11 (OR = 0.9; 95%CI (0.4, 2.6)]. There were differences in pro-social behaviours among those surveyed before/after the school holidays at age 14 [OR = 1.2; 95%CI (0.5, 3.5)] but not at age 7 or 11. There was little change in inequalities in verbal cognitive ability scores over the school holidays [Age 7: b = 1.3; 95%CI (- 3.3, 6.0); Age 11: b = - 0.7; 95%CI (- 4.3, 2.8); Age 14: b = - 0.3; 95%CI (- 1.0, 0.4)].

CONCLUSION

We found inequalities in mental health and cognitive ability according to maternal education, and some evidence or worsening mental health and mental health inequalities across school summer holidays. We found little evidence of widening inequalities in verbal cognitive ability. Widespread school closures during the COVID-19 restrictions have prompted concerns that prolonged closures may widen health and educational inequalities. Management of school closures should focus on preventing or mitigating inequalities that may arise from differences in the support for mental health and learning provided during closures by schools serving more or less disadvantaged children.

Process and impact of implementing a smoke-free policy in prisons in Scotland: TIPs mixed-methods study

Background

Prisons had partial exemption from the UK’s 2006/7 smoking bans in enclosed public spaces. They became one of the few workplaces with continuing exposure to second-hand smoke, given the high levels of smoking among people in custody. Despite the introduction of smoke-free prisons elsewhere, evaluations of such ‘bans’ have been very limited to date.

Objective

The objective was to provide evidence on the process and impact of implementing a smoke-free policy across a national prison service.

Design

The Tobacco in Prisons study was a three-phase, multimethod study exploring the periods before policy formulation (phase 1: pre announcement), during preparation for implementation (phase 2: preparatory) and after implementation (phase 3: post implementation).

Setting

The study was set in Scotland’s prisons.

Participants

Participants were people in custody, prison staff and providers/users of prison smoking cessation services.

Intervention

Comprehensive smoke-free prison rules were implemented across all of Scotland’s prisons in November 2018.

Main outcome measures

The main outcome measures were second-hand smoke levels, health outcomes and perspectives/experiences, including facilitators of successful transitions to smoke-free prisons.

Data sources

The study utilised cross-sectional surveys of staff (total, n = 3522) and people in custody (total, n = 5956) in each phase; focus groups and/or one-to-one interviews with staff (n = 237 across 34 focus groups; n = 38 interviews), people in custody (n = 62 interviews), providers (n = 103 interviews) and users (n = 45 interviews) of prison smoking cessation services and stakeholders elsewhere (n = 19); measurements of second-hand smoke exposure (e.g. 369,208 minutes of static measures in residential areas at three time points); and routinely collected data (e.g. medications dispensed, inpatient/outpatient visits).

Results

Measures of second-hand smoke were substantially (≈ 90%) reduced post implementation, compared with baseline, largely confirming the views of staff and people in custody that illicit smoking is not a major issue post ban. Several factors that contributed to the successful implementation of the smoke-free policy, now accepted as the ‘new normal’, were identified. E-cigarette use has become common, was recognised (by both staff and people in custody) to have facilitated the transition and raises new issues in prisons. The health economic analysis (lifetime model) demonstrated that costs were lower and the number of quality-adjusted life-years was larger for people in custody and staff in the ‘with smoke-free’ policy period than in the ‘without’ policy period, confirming cost-effectiveness against a £20,000 willingness-to-pay threshold.

Limitations

The ability to triangulate between different data sources mitigated limitations with constituent data sets.

Conclusions

To our knowledge, this is the first study internationally to analyse the views of prison staff and people in custody; objective measurements of second-hand smoke exposure and routine health and other outcomes before, during and after the implementation of a smoke-free prison policy; and to assess cost-effectiveness. The results are relevant to jurisdictions considering similar legislation, whether or not e-cigarettes are permitted. The study provides a model for partnership working and, as a multidimensional study of a national prison system, adds to a previously sparse evidence base internationally.

Future work

Priorities are to understand how to support people in custody in remaining smoke free after release from prison, and whether or not interventions can extend benefits to their families; to evaluate new guidance supporting people wishing to reduce or quit vaping; and to understand how prison vaping practices/cultures may strengthen or weaken long-term reductions in smoking.

Study registration

This study is registered as Research Registry 4802.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 1. See the NIHR Journals Library website for further project information.

Guidance on the assessment of exposure of operators, workers, residents and bystanders in risk assessment of plant protection products

This guidance is designed to assist risk assessors and applicants when quantifying potential non-dietary, systemic exposures as part of regulatory risk assessment for plant protection products (PPPs). It is based on the Scientific Opinion on 'Preparation of a Guidance Document on Pesticide Exposure Assessment for Workers, Operators, Residents and Bystanders' developed by the EFSA Panel on Plant Protection Products and their Residue (PPR) in 2010. Highlighting some inconsistencies between the approaches adopted by regulatory authorities, the PPR Panel proposed a number of changes to the practices in use (i.e. use of deterministic methods for individual PPPs; need to perform an acute risk assessment for PPPs that are acutely toxic; use of appropriate percentile for acute or longer term risk assessments). In the first version of the guidance, issued in 2014, several scenarios for outdoor uses were included, with an annexed calculator, as well as recommendations for further research. The guidance has been updated in 2021 with the inclusion of additional scenarios and revision of default values, on the basis of the evaluation of additional evidence. To support users in performing the assessment of exposure and risk, an online calculator, reflecting the guidance content, has been further developed.

Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare neuroendocrine carcinoma. The cellular origin of MCC may include Merkel cell precursors. The incidence of MCC has increased significantly however trends may have been confounded by evolving diagnostic criteria. The two key aetiologies of MCC are ultraviolet radiation and Merkel cell polyoma virus (MCPyV). Both have unique mechanisms of carcinogenesis. MCC presents non-specifically as a rapidly growing, red-to-violet nodule on sun-exposed areas. Diagnostic accuracy has improved through immunohistochemical markers such as CK-20. Lymph nodes should be evaluated in MCC through examination and sentinel biopsy. USS, CT, MRI and CT-PET may be useful in staging. Management depends on tumour location, stage and comorbidities. MCPyV status may guide treatment strategy in the future. Treatment for the primary MCC is commonly wide local excision followed by radiotherapy, guided by anatomical constraints. There is uncertainty about surgical margins. Treatments for nodal disease have not been determined through trials. They include nodal dissection or radiotherapy for clinically or radiologically apparent disease, and adjuvant nodal irradiation for negative nodes, microscopic disease or following nodal dissection for definite disease. Patients with loco-regional advanced inoperable disease should be considered for combination therapy including chemotherapy, radiotherapy, surgery and immunotherapy. Systemic therapy for advanced disease includes immune checkpoint inhibitors targeting the PD-1/PD-L1 pathway. Avelumab can improve survival in metastatic MCC. Immunotherapy may result in longer disease control. Various other immunotherapeutic and molecular agents are undergoing trials. MCC continues to have a high mortality characterized by high recurrence and early metastases.

Cochrane's risk of bias tool for non-randomized studies (ROBINS-I) is frequently misapplied: A methodological systematic review

OBJECTIVES

We aimed to review how 'Risk of Bias In Non-randomized Studies-of Interventions' (ROBINS-I), a Cochrane risk of bias assessment tool, has been used in recent systematic reviews.

STUDY DESIGN AND SETTING

Database and citation searches were conducted in March 2020 to identify recently published reviews using ROBINS-I. Reported ROBINS-I assessments and data on how ROBINS-I was used were extracted from each review. Methodological quality of reviews was assessed using AMSTAR 2 ('A MeaSurement Tool to Assess systematic Reviews').

RESULTS

Of 181 hits, 124 reviews were included. Risk of bias was serious/critical in 54% of assessments on average, most commonly due to confounding. Quality of reviews was mostly low, and modifications and incorrect use of ROBINS-I were common, with 20% reviews modifying the rating scale, 20% understating overall risk of bias, and 19% including critical-risk of bias studies in evidence synthesis. Poorly conducted reviews were more likely to report low/moderate risk of bias (predicted probability 57% [95% CI: 47-67] in critically low-quality reviews, 31% [19-46] in high/moderate-quality reviews).

CONCLUSION

Low-quality reviews frequently apply ROBINS-I incorrectly, and may thus inappropriately include or give too much weight to uncertain evidence. Readers should be aware that such problems can lead to incorrect conclusions in reviews.

Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis

BACKGROUND

Internationally, smoking prevalence among people in prison custody (ie, people on remand awaiting trial, awaiting sentencing, or serving a custodial sentence) is high. In Scotland, all prisons implemented a comprehensive smoke-free policy in 2018 after a 16-month anticipatory period. In this study, we aimed to use data on medication dispensing to assess the impact of this policy on cessation support, health outcomes, and potential unintended consequences among people in prison custody.

METHODS

We did an interrupted time-series analysis using dispensing data for 44 660 individuals incarcerated in 14 closed prisons in Scotland between March 30, 2014, and Nov 30, 2019. We estimated changes in dispensing rates associated with the policy announcement (July 17, 2017) and full implementation (Nov 30, 2018) using seasonal autoregressive integrated moving average models. Medication categories of primary interest were treatments for nicotine dependence (as an indicator of smoking cessation or abstinence attempts), acute smoking-associated illnesses, and mental health (antidepressants). We included antiepileptic medications as a negative control.

FINDINGS

A 44% step increase in dispensing of treatments for nicotine dependence was observed at implementation (2250 items per 1000 people in custody per fortnight, 95% CI 1875 to 2624) due primarily to a 42% increase in dispensing of nicotine replacement therapy (2109 items per 1000 people in custody per fortnight, 1701 to 2516). A 9% step decrease in dispensing for smoking-related illnesses was observed at implementation, largely accounted for by respiratory medications (-646 items per 1000 people in custody per fortnight, -1111 to -181). No changes associated with announcement or implementation were observed for mental health dispensing or antiepileptic medications (control).

INTERPRETATION

Smoke-free prison policies might improve respiratory health among people in custody and encourage smoking abstinence or cessation without apparent short-term adverse effects on mental health dispensing.

FUNDING

National Institute of Health Research Public Health Research programme, Scottish Government Chief Scientist Office, and UK Medical Research Council.

Introduction to the complex intervention concept and the research perspectives

 

Few interventions are truly simple; complexity can arise from various sources, e.g.:

Aspects of the intervention itself, such as the number of intervention components, the number of groups targeted, how dynamic the intervention is permitted to be. The context in which the intervention is developed and delivered, such as the social, political, economic, and geographical context.

Complex intervention research should be approached with an awareness of these sources of complexity. Systems thinking can be helpful to understanding the dynamic interaction between interventions and their context. This presentation will introduce concepts of complex adaptive systems, e.g. feedback loops, adaptation, emergence, that should be considered when developing and evaluating complex interventions. It will then introduce participants to the research perspectives set out in the new framework: efficacy, effectiveness, theory-based, and systems perspectives. Each perspective is associated with a different type of research question, and therefore appropriate in different circumstances. The presentation will provide information to support participants to consider the research perspective(s) most suited to the research challenge that they are aiming to address.

Main messages

There are multiple sources of complexity, each of which can affect how the intervention works or contributes to change. Complex intervention research can take an efficacy, effectiveness, theory-based, or systems perspective, the choice of which is based on what is known already and what further evidence would be most useful.

The new Framework and the Core Elements of complex intervention research

 

The new framework will be presented. The main phases of intervention research: development or identification, feasibility, evaluation and implementation are connected to 6 core elements:

Context: any feature of the circumstances in which an intervention is conceived, developed, evaluated and implemented Programme theory: how an intervention is expected to lead to its effects and under what conditions. Programme theory should be tested and refined at all stages and used to guide the identification of uncertainties and research questions Stakeholders: those who are targeted by the intervention, involved in its development or delivery, or more broadly those whose personal or professional interests are affected, that is who have a stake in the topic. This includes patients, the public, and professionals Refinement: the process of ‘fine tuning' or making changes to the intervention once a preliminary version has been developed Uncertainties: identifying key uncertainties that exist given what is already known and what the programme theory, researchers and stakeholders identify as being most important to find out. These judgements inform the framing of research questions that, in turn, govern research perspective choice Economic considerations: exploring the comparative resource and outcome consequences of the interventions for those people and organisations affected

The presentation will discuss how to use the framework, highlighting that complex intervention research can be an iterative process. Repeating of phases is preferable to automatic progression to the next phase if uncertainties remain unresolved.

Main messages

Complex intervention research may begin at any phase, depending on what is appropriate for the intervention in question, and does not necessarily move sequentially through the phases. The core elements should be considered early and revisited continually throughout, as this will make it most likely that the intervention will be implementable in practice.

Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update

BACKGROUND

The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods.

METHODS

There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments.

RESULTS

Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout.

LIMITATIONS

The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development.

CONCLUSIONS

This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers.

FUTURE WORK

We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources.

FUNDING

This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).

Brine-driven destruction of clay minerals in Gale crater, Mars

Mars' sedimentary rock record preserves information on geological (and potential astrobiological) processes that occurred on the planet billions of years ago. The Curiosity rover is exploring the lower reaches of Mount Sharp, in Gale crater on Mars. A traverse from Vera Rubin ridge to Glen Torridon has allowed Curiosity to examine a lateral transect of rock strata laid down in a martian lake ~3.5 billion years ago. We report spatial differences in the mineralogy of time-equivalent sedimentary rocks <400 meters apart. These differences indicate localized infiltration of silica-poor brines, generated during deposition of overlying magnesium sulfate-bearing strata. We propose that destabilization of silicate minerals driven by silica-poor brines (rarely observed on Earth) was widespread on ancient Mars, because sulfate deposits are globally distributed.

An N-of-1 study of daily alcohol consumption following minimum unit pricing implementation in Scotland

BACKGROUND AND AIMS

Within the context of Scotland's policy change to implement a minimum unit price (MUP) per unit of alcohol sold in licensed premises, this study used an N-of-1 design to assess between-person differences in the psychological and social factors associated with daily alcohol consumption.

DESIGN AND SETTING

A mixed-methods approach combined N-of-1 observational studies, comprising daily surveys followed by qualitative social network interviews (not reported here). Peer researchers with lived experience of substance use were involved in the study design and fieldwork was conducted in towns and rural areas in the East of Scotland.

PARTICIPANTS/CASES

Twenty-five adults with current or recent history of alcohol dependence recruited for three 12-week waves: 11 in wave 1 (pre-MUP), 11 in wave 2 (pre- and post-MUP) and three in wave 3 (post MUP).

MEASUREMENTS

Gender, age, alcohol and other drug use history. Daily surveys for 12 weeks captured information about factors in the last 24 hours, e.g. amount and type of alcohol consumed, stress, social contact.

FINDINGS

Each participant was in the daily survey for a mean of 64 days [standard deviation (SD) = 42; median = 59], with a response rate of 48%; 15 participants provided sufficient data for analysis. Factors related to daily alcohol consumption differed between individuals. Models suggested that some individuals with high initial consumption reduced drinking after MUP, but explanatory factors differed, e.g. changing motivation was important for some, while alcohol availability was important for others.

CONCLUSIONS

Adapting N-of-1 methods for an observational study uncovered differences in alcohol consumption change before and after minimum unit pricing implementation in Scotland, evidence of individual differences in the factors relating to alcohol consumption patterns and some evidence that post-MUP consumption changes may be related to changing psychosocial factors.

Mental health and health behaviours before and during the initial phase of the COVID-19 lockdown: longitudinal analyses of the UK Household Longitudinal Study

BACKGROUND

There are concerns that COVID-19 mitigation measures, including the 'lockdown', may have unintended health consequences. We examined trends in mental health and health behaviours in the UK before and during the initial phase of the COVID-19 lockdown and differences across population subgroups.

METHODS

Repeated cross-sectional and longitudinal analysis of the UK Household Longitudinal Study, including representative samples of over 27,000 adults (aged 18+) interviewed in four survey waves between 2015 and 2020. A total of 9748 adults had complete data for longitudinal analyses. Outcomes included psychological distress (General Health Questionnaire-12), loneliness, current cigarette smoking, use of e-cigarettes and alcohol consumption. Cross-sectional prevalence estimates were calculated and multilevel Poisson regression assessed associations between time period and the outcomes of interest, as well as differential associations by age, gender, education level and ethnicity.

RESULTS

Psychological distress increased 1 month into lockdown with the prevalence rising from 19.4% (95% CI 18.7% to 20.1%) in 2017-2019 to 30.6% (95% CI 29.1% to 32.3%) in April 2020 (RR=1.3, 95% CI 1.2 to 1.4). Groups most adversely affected included women, young adults, people from an Asian background and those who were degree educated. Loneliness remained stable overall (RR=0.9, 95% CI 0.6 to 1.5). Smoking declined (RR=0.9, 95% CI=0.8,1.0) and the proportion of people drinking four or more times per week increased (RR=1.4, 95% CI 1.3 to 1.5), as did binge drinking (RR=1.5, 95% CI 1.3 to 1.7).

CONCLUSIONS

Psychological distress increased 1 month into lockdown, particularly among women and young adults. Smoking declined, but adverse alcohol use generally increased. Effective measures are required to mitigate negative impacts on health.

Mental health and health behaviours before and during the initial phase of the COVID-19 lockdown: longitudinal analyses of the UK Household Longitudinal Study

BACKGROUND

There are concerns that COVID-19 mitigation measures, including the 'lockdown', may have unintended health consequences. We examined trends in mental health and health behaviours in the UK before and during the initial phase of the COVID-19 lockdown and differences across population subgroups.

METHODS

Repeated cross-sectional and longitudinal analysis of the UK Household Longitudinal Study, including representative samples of over 27,000 adults (aged 18+) interviewed in four survey waves between 2015 and 2020. A total of 9748 adults had complete data for longitudinal analyses. Outcomes included psychological distress (General Health Questionnaire-12), loneliness, current cigarette smoking, use of e-cigarettes and alcohol consumption. Cross-sectional prevalence estimates were calculated and multilevel Poisson regression assessed associations between time period and the outcomes of interest, as well as differential associations by age, gender, education level and ethnicity.

RESULTS

Psychological distress increased 1 month into lockdown with the prevalence rising from 19.4% (95% CI 18.7% to 20.1%) in 2017-2019 to 30.6% (95% CI 29.1% to 32.3%) in April 2020 (RR=1.3, 95% CI 1.2 to 1.4). Groups most adversely affected included women, young adults, people from an Asian background and those who were degree educated. Loneliness remained stable overall (RR=0.9, 95% CI 0.6 to 1.5). Smoking declined (RR=0.9, 95% CI=0.8,1.0) and the proportion of people drinking four or more times per week increased (RR=1.4, 95% CI 1.3 to 1.5), as did binge drinking (RR=1.5, 95% CI 1.3 to 1.7).

CONCLUSIONS

Psychological distress increased 1 month into lockdown, particularly among women and young adults. Smoking declined, but adverse alcohol use generally increased. Effective measures are required to mitigate negative impacts on health.

Evaluating the health effect of a Social Housing programme, Minha Casa Minha Vida, using the 100 million Brazilian Cohort: a natural experiment study protocol

INTRODUCTION

Social housing programmes have been shown to influence health, but their effects on cardiovascular mortality and incidence of infectious diseases, such as leprosy and tuberculosis, are unknown. We will use individual administrative data to evaluate the effect of the Brazilian housing programme Minha Casa Minha Vida (MCMV) on cardiovascular disease (CVD) mortality and incidence of leprosy and tuberculosis.

METHODS AND ANALYSIS

We will link the baseline of the 100 Million Brazilian Cohort (2001-2015), which includes information on socioeconomic and demographic variables, to the MCMV (2009-2015), CVD mortality (2007-2015), leprosy (2007-2015) and tuberculosis (2007-2015) registries. We will define our exposed population as individuals who signed the contract to receive a house from MCMV, and our non-exposed group will be comparable individuals within the cohort who have not signed a contract for a house at that time. We will estimate the effect of MCMV on health outcomes using different propensity score approaches to control for observed confounders. Follow-up time of individuals will begin at the date of exposure ascertainment and will end at the time a specific outcome occurs, date of death or end of follow-up (31 December 2015). In addition, we will conduct stratified analyses by the follow-up time, age group, race/ethnicity, gender and socioeconomic position.

ETHICS AND DISSEMINATION

The study was approved by the ethic committees from Instituto Gonçalo Muniz-Oswaldo Cruz Foundation and University of Glasgow Medical, Veterinary and Life Sciences College. Data analysis will be carried out using an anonymised dataset, accessed by researchers in a secure computational environment according to the Centre for Integration of Data and Health Knowledge procedures. Study findings will be published in high quality peer-reviewed research journals and will also be disseminated to policy makers through stakeholder events and policy briefs.

Conceptualising natural and quasi experiments in public health

Background

Natural or quasi experiments are appealing for public health research because they enable the evaluation of events or interventions that are difficult or impossible to manipulate experimentally, such as many policy and health system reforms. However, there remains ambiguity in the literature about their definition and how they differ from randomized controlled experiments and from other observational designs. We conceptualise natural experiments in the context of public health evaluations and align the study design to the Target Trial Framework.

Methods

A literature search was conducted, and key methodological papers were used to develop this work. Peer-reviewed papers were supplemented by grey literature.

Results

Natural experiment studies (NES) combine features of experiments and non-experiments. They differ from planned experiments, such as randomized controlled trials, in that exposure allocation is not controlled by researchers. They differ from other observational designs in that they evaluate the impact of events or process that leads to differences in exposure. As a result they are, in theory, less susceptible to bias than other observational study designs. Importantly, causal inference relies heavily on the assumption that exposure allocation can be considered ‘as-if randomized’. The target trial framework provides a systematic basis for evaluating this assumption and the other design elements that underpin the causal claims that can be made from NES.

Conclusions

NES should be considered a type of study design rather than a set of tools for analyses of non-randomized interventions. Alignment of NES to the Target Trial framework will clarify the strength of evidence underpinning claims about the effectiveness of public health interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01224-x.

Regression Discontinuity Designs in Health: A Systematic Review

BACKGROUND

Regression discontinuity designs are non-randomized study designs that permit strong causal inference with relatively weak assumptions. Interest in these designs is growing but there is limited knowledge of the extent of their application in health. We aimed to conduct a comprehensive systematic review of the use of regression discontinuity designs in health research.

METHODS

We included studies that used regression discontinuity designs to investigate the physical or mental health outcomes of any interventions or exposures in any populations. We searched 32 health, social science, and gray literature databases (1 January 1960 to 1 January 2019). We critically appraised studies using eight criteria adapted from the What Works Clearinghouse Standards for regression discontinuity designs. We conducted a narrative synthesis, analyzing the forcing variables and threshold rules used in each study.

RESULTS

The literature search retrieved 7658 records, producing 325 studies that met the inclusion criteria. A broad range of health topics was represented. The forcing variables used to implement the design were age, socioeconomic measures, date or time of exposure or implementation, environmental measures such as air quality, geographic location, and clinical measures that act as a threshold for treatment. Twelve percent of the studies fully met the eight quality appraisal criteria. Fifteen percent of studies reported a prespecified primary outcome or study protocol.

CONCLUSIONS

This systematic review demonstrates that regression discontinuity designs have been widely applied in health research and could be used more widely still. Shortcomings in study quality and reporting suggest that the potential benefits of this method have not yet been fully realized.

Evaluating the impact of the Bolsa Familia conditional cash transfer program on premature cardiovascular and all-cause mortality using the 100 million Brazilian cohort: a natural experiment study protocol

INTRODUCTION

Brazil's Bolsa Familia Program (BFP) is the world's largest conditional cash transfer scheme. We shall use a large cohort of applicants for different social programmes to evaluate the effect of BFP receipt on premature all-cause and cardiovascular mortality.

METHODS AND ANALYSIS

We will identify BFP recipients and non-recipients among new applicants from 2004 to 2015 in the 100 Million Brazilian Cohort, a database of 114 million individuals containing sociodemographic and mortality information of applicants to any Brazilian social programme. For individuals applying from 2011, when we have better recorded income data, we shall compare premature (age 30-69) cardiovascular and all-cause mortality among BFP recipients and non-recipients using regression discontinuity design (RDD) with household monthly per capita income as the forcing variable. Effects will be estimated using survival models accounting for individuals follow-up. To test the sensitivity of our findings, we will estimate models with different bandwidths, include potential confounders as covariates in the survival models, and restrict our data to locations with the most reliable data. In addition, we will estimate the effect of BFP on studied outcomes using propensity score risk-set matching, separately for individuals that applied ≤2010 and >2011, allowing comparability with RDD. Analyses will be stratified by geographical region, gender, race/ethnicity and socioeconomic position. We will investigate differential impacts of BFP and the presence of effect modification for a combination of characteristics, including gender and race/ethnicity.

ETHICS AND DISSEMINATION

The study was approved by the ethics committees of Oswaldo Cruz Foundation and the University of Glasgow College of Medicine and Veterinary Life Sciences. The deidentified dataset will be provided to researchers, and data analysis will be performed in a safe computational environment without internet access. Study findings will be published in high quality peer-reviewed research articles. The published results will be disseminated in the social media and to policy-makers.

Economic impacts of implementing a national smoke-free prison policy

Background

Worldwide, over 600,000 non-smokers are killed annually due to exposure to secondhand smoke (SHS); the UK societal cost of SHS is estimated at £700million per annum. Prior to recent smoke free policy in Scottish prisons smoking rates were very high (70-75%), well above population rates, subjecting people in custody (PiC) and prison staff to high levels of SHS. Eradicating SHS exposure in prisons could lead to improved health in previous smokers and non-smokers alike, and decrease demand on the National Health Service. However, to date, there is little evidence relating to the economic impact of smoking bans in prisons.

Methods

An economic evaluation estimating the short-term and lifetime impacts of smokefree prison policy in Scotland policy used data from the TIPs study (Jun 2016-Nov 2019) for prison staff and PiC. The analyses adopted a public health and personal perspective and key resources included: implementation costs, cessation support services, health service use and personal costs. For the short-term analyses data were sourced from TIPs staff and PiC surveys, and routine data from the Scottish Prison Service and NHS National Services Scotland. Outcomes included SHS exposure, staff sickness absence, violent incidents and quality adjusted life years (QALYs). The life-time analysis used a Markov model to estimate cost per QALY for both staff and PiC.

Results

SHS exposure measures show a median reduction of 91%. Costs and economic outcome results (mean cost pre- and post-ban, cost-consequences balance sheet and incremental cost per QALYs) are confidential until May 2020 due to their sensitivity and will be available to present at EUPHA 2020.

Conclusions

Previous economic evaluations have focussed on smoking bans in public places and raising the smoking age. This is the first economic analysis of a national prison smoking ban and analysis will be of interest to prison services in other jurisdictions which have yet to implement smokefree policy.

Smokefree policy and medication dispensing for people in prison: interrupted time series analysis

Background

Previous evaluations of smokefree prison policies have suggested improvements in self-rated health and some smoking-related symptoms. No studies to date have investigated impacts on medication use as proxy measures of objective ill-health or as indicators of potential negative unintended consequences. These is limited evidence to date on these important outcomes.

Methods

We obtained from NHS National Services Scotland aggregate data on medication items dispensed in prisons, based on individual named patient medication records, and from the Scottish Prison Service data on the prison population, for the period Jan 2013-Nov 2019. Items of interest comprised those for smoking cessation (varenicline and buproprion); nicotine replacement; specific smoking-related health conditions (glyceryl trinitrate; inhaled bronchodilators and steroids; antibiotics; chloramphenicol eye drops; and proton pump inhibitors and H2 receptor antagonists), and potential unintended mental health consequences (anti-depressants). We also included a set of negative controls for which dispensing was not expected to be affected by the new smokefree policy (anticonvulsants, excluding pregabalin and gabapentin). Analyses were undertaken using AutoRegressive Integrated Moving Average (ARIMA) time series methods, with the dates of the policy's announcement and of implementation included as pre-specified breakpoints.

Results

The results of ARIMA modelling of medication dispensing are confidential until May 2020 due to their sensitivity and will be available to present at WCPH 2020.

Conclusions

The use of routinely available dispensing data as an indicator of objective health impacts and potential negative unintended consequences provides novel insights into the effectiveness of smokefree prison policies. Results will be of interest to international jurisdictions considering such policies and to those seeking to harness the potential of administrative data for natural experiments.

The Brazilian conditional cash transfer program and cardiovascular mortality: a data linkage study

Background

Conditional cash transfer programmes (CCTs) make monetary transfers to poor families conditional on health check-ups and/or education attendance. CCTs have been key in reducing poverty and improving child and maternal health in low- and middle-income countries (LMICs) but their impact on cardiovascular mortality have not been studied. We aimed to evaluate the effect of the CCT Bolsa Familia Program (BFP) on premature all-cause and cardiovascular mortality in Brazil.

Methods

The 100 Million Brazilian Cohort combined information about individuals applying for social programmes, the BFP and mortality data. We analysed ∼8 million individuals aged 30-69 who applied from 2011 to 2015. We calculated inverse probability weights (IPW) for the probability to receive BFP based on baseline observed characteristics (age, education, race, geographical location, household characteristics and year of application). Individuals were followed until they reached 70 years of age, died by any cause, or until 31st Dec 2015. We used Poisson regression (with person-years as the offset) and IPWs to compare BFP recipients to a comparable control population. Females and males were analysed separately.

Results

By following individuals for up to 4 years, 43,562 deaths by all-causes occurred among 4,197,658 females and 69,209 deaths among 3,672,393 males. Female BFP beneficiaries had approximately 60% lower all-cause mortality (IRR=0.40;95%CI=0.37-0.42) and CVD mortality (IRR=0.42;95%CI=0.37-0.47) than non-beneficiaries. Males who are BFP beneficiaries had ∼50% lower all-cause (IRR=0.53;95%CI=0.52-0.55) and 60% lower cardiovascular mortality (IRR=0.40;95%CI=0.38-0.42) than non-beneficiaries.

Conclusions

BFP, the world's largest CCT, may substantially decrease premature mortality. CCTs might have important implications for the growing burden of non-communicable diseases, with impacts potentially due to improved nutrition, socioeconomic conditions and improved primary care access.

Key messages

The Brazilian CCT, a widely recognized programme for poverty alleviation, have showed to be associated with lower overall and cardiovascular premature mortality in both women and men. Other countries, particularly LMICs, may learn from the health benefits of CCTs and should consider its potential large effect on mortality when planning austerity policies.

ADAPT study: adaptation of evidence-informed complex population health interventions for implementation and/or re-evaluation in new contexts: protocol for a Delphi consensus exercise to develop guidance

INTRODUCTION

Complex population health interventions that are effective in one context may not be effective elsewhere, and may even be harmful. As such, an intervention may require adaptation to ensure it fits with a new context. To date, there is no overarching guidance to help researchers to adapt and evaluate interventions in new contexts, and no criteria to support research funders or journals assess proposed or reported adaptations or evaluation. There is limited assistance for policy-makers and practitioners to decide if evidence-informed interventions are appropriate to their context, or if adaptation and further evaluation is needed. This Delphi exercise will contribute to the development of guidance for these communities to support the adaptation, implementation and/or re-evaluation of complex population health interventions in new contexts.

METHODS

We will conduct a Delphi consensus exercise to gather expert opinion from researchers, research funders, journal editors and policy-makers. Expert opinion will be sought on: appropriate definitions and concepts, identifying key methodological considerations and establishing adaptations and processes to be undertaken during adaptation of complex population health interventions in new contexts.

ETHICS AND DISSEMINATION

Ethics approval for the Delphi exercise has been obtained from the University of Glasgow and and the RAND institutional research board. Dissemination of the results of this study will be through peer-reviewed publications, workshops at national and international conferences, and a summary of the guidance developed for key organisations and stakeholders.

Ten years on: increased metal ion levels in a cohort of patients who underwent uncemented metal-on-polyethylene total hip arthroplasty

Aims

We have previously demonstrated raised cobalt and chromium levels in patients with larger diameter femoral heads, following metal-on-polyethylene uncemented total hip arthroplasty. Further data have been collected, to see whether these associations have altered with time and to determine the long-term implications for these patients and our practice.

Methods

Patients from our previous study who underwent Trident-Accolade primary total hip arthroplasties using a metal-on-polyethylene bearing in 2009 were reviewed. Patients were invited to have their cobalt and chromium levels retested, and were provided an Oxford Hip Score. Serum ion levels were then compared between groups (28 mm, 36 mm, and 40 mm heads) and over time.

Results

Metal ion levels were repeated in 33 patients. When comparing the results of serum metal ion levels over time, regardless of head size, there was a significant increase in both cobalt and chromium levels (p < 0.001). Two patients with larger head sizes had undergone revision arthroplasty with evidence of trunnion damage at surgery. Two patients within the 40 mm subgroup had metal ion levels above the MHRA (Medicines and Healthcare Products Regulatory Agency) threshold for detailed investigation. The increase in cobalt and chromium, when comparing the 36 mm and 40 mm groups with those of the 28 mm group, was not significant (36 mm vs 28 mm; p = 0.092/p = 0.191; 40 mm vs 28 mm; p = 0.200/p = 0.091, respectively). There was no difference, between femoral head sizes, when comparing outcome as measured by the Oxford Hip Score.

Conclusion

This study shows an increase in cobalt and chromium levels over time for all modular femoral head sizes in patients with metal-on-polyethylene bearings, with two patients demonstrating ion levels above the MHRA threshold for failure, and a further two patients requiring revision surgery. These results may have clinical implications regarding longer term follow-up of patients and future implant choice, particularly among younger patients. Cite this article: Bone Joint J 2020;102-B(7):832–837.

Impact of UK Tobacco Control Policies on Inequalities in Youth Smoking Uptake: A Natural Experiment Study

INTRODUCTION

UK countries implemented smoke-free public places legislation and increased the legal age for tobacco purchase from 16 to 18 years between 2006 and 2008. We evaluated the immediate and long-term impacts of these UK policy changes on youth smoking uptake and inequalities therein.

AIMS AND METHODS

We studied 74 960 person-years of longitudinal data from 14 992 youths (aged 11-15 years) in annual UK household surveys between 1994 and 2016. Discrete-time event history analyses examined whether changes in rates of youth smoking transitions (initiation, experimentation, and escalation to daily smoking or quitting) or their inequalities (by parental education) were associated with policy implementation. Parallel analyses examined smoke-free legislation and the change in legal age. We interpret the results as a combined effect of the two pieces of legislation as their implementation dates were too close to identify separate effects. Models were adjusted for sex, age, UK country, historical year, tobacco taxation, and e-cigarette prevalence, with multiple imputation for missing data.

RESULTS

For both policies, smoking initiation reduced following implementation (change in legal age odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.55 to 0.81; smoke-free legislation OR: 0.68; 95% CI: 0.56 to 0.82), while inequalities in initiation narrowed over subsequent years. The legal age change was associated with annual increases in progression from initiation to occasional smoking (OR: 1.26; 95% CI: 1.07 to 1.50) and a reduction in quitting following implementation (OR: 0.57; 95% CI: 0.35 to 0.94). Similar effects were observed for smoke-free legislation but CIs overlapped the null.

CONCLUSIONS

Policies such as these may be highly effective in preventing and reducing socioeconomic inequalities in youth smoking initiation.

IMPLICATIONS

UK implementation of smoke-free legislation and an increase in the legal age for tobacco purchase from 16 to 18 years were associated with an immediate reduction in smoking initiation and a narrowing of inequalities in initiation over subsequent years. While the policies were associated with reductions in the initiation, progression to occasional smoking increased and quitting decreased following the legislation.