Journal of Public Health

BackgroundThe public health grant is used by upper-tier and unitary local authorities in England to fund public health services. Public health grant allocations have declined by 26% per person since 2015/16, with cuts being made without any adjustment based on population needs, resulting in absolute cuts often being greater for more deprived local authorities. This study seeks to investigate how these cuts have affected spending decisions across different areas of public health and how changes in spend relate to population health needs. MethodsIn this longitudinal ecological study, data on local government revenue expenditure and financing to 146 upper-tier local authorities in England were extracted from the Ministry of Housing, Communities, and Local Government for the years 2017/18, 2018/19 2019/20 and 2022/23. Demand for each function of the public health grant was proxied using a publicly available indicator of need. Descriptive analyses explored changes to grant expenditure over time by function and IMD quintile. A compositional regression model was developed to account for the relatedness of spend data. The significance of associations between indicators of need and spend on functions of the grant was tested using MANOVA, producing Pillais Trace statistics as an indication of the effect size of each explanatory variable relative to others. FindingsPublic health grant spending reductions were widespread. More deprived local authorities often experienced deeper absolute cuts against a backdrop of greater need, with spend being protected across all IMD quintiles in only three areas: childrens 0 to 5 non-prescribed functions, health protection, and public mental health. In the multivariate regression, there was limited relationship between indicators of health need and patterns of grant spend between public health categories. InterpretationThere is no clear relationship between potential indicators of need and expenditure of the public health grant in different reporting categories. Instead, spending decisions are being driven by other factors that may include historic spend, wider local priorities and financial pressures. These findings suggest a review of the public health grant formula to support local authority public health teams to more strategically apportion spend based on population health need. O_LIWhat is already known on this topic O_LILocal authority public health teams in England receive a ring-fenced grant from central government which was originally based on an allocation formula that has not been updated since 2012/13. C_LIO_LIThe grant has been cut substantially over the past decade, often with larger absolute cuts for more deprived local authorities. C_LIO_LINo previous study has investigated how public health teams allocate a diminishing grant across competing areas of public health need and how this may vary by deprivation. C_LI C_LIO_LIWhat this study adds O_LIThis study found limited evidence that indicators of health need have driven public health grant allocation in related spend categories, nor any differences by deprivation. Our analysis is the first to explore multiple indicators of need and to employ compositional regression to account for corelations between categories of grant spend. C_LI C_LIO_LIHow this study might affect research, practice and policy O_LIThis study supports a review of the public health grant funding formula to better distribute the public health grant according to local population health need. C_LI C_LI

ObjectiveTo re-estimate and re-validate the Area Deprivation Index to address recent criticism of the existing index, which is calculated and distributed by Neighborhood Atlas. Data SourcesTo calculate the updated Area Deprivation Index (ADI), we obtained 17 census measures from the 2018-2022 American Community Survey (ACS) 5-year data that reflected poverty, housing, employment, and education within census block groups, census tracts, and counties. To validate the association of the updated index with health outcomes, we obtained the most recent census tract-level life table data from the U.S. Small-area Life Expectancy Estimates Project (USALEEP). Study DesignWe used principal components analysis to estimate new factor weights associated with the primary component summarizing the 17 selected census measures. The resulting scores were ranked into percentiles to arrive at the updated ADI. We compared this updated ADI to the existing ADI distributed by the Neighborhood Atlas. We calculated average life expectancy and age-specific mortality rates by groups defined by the updated ADI. Principal FindingsThe principal components analysis identified a single factor that explained 46% of variance at the census tract level. There were noticeable differences in factor loadings for the unemployment rate and the proportion of households without a motor vehicle compared to the original loadings. Results were similar at the county and block group levels. Compared to existing ADI values, there were substantive changes in the updated ADI values for many geographic ares with high home values, but low employment and educational attainment. The updated ADI demonstrated robust associations with age-specific mortality and life expectancy. ConclusionsThe updated ADI better summarized the 17 underlying census variables than the current ADI. The updated index was strongly correlated with life expectancy and mortality. Callout BoxWhat is known on this topic O_LIADI is a measure of area-level deprivation that summarizes 17 Census measures regarding poverty, housing, employment, and education. The original ADI demonstrated associations with mortality and clinical outcomes. C_LIO_LIThe current version of the ADI made available by the Neighborhood Atlas relies on old factor weights and appears to have flaws in its construction that lead to overreliance on home value and income variables. C_LI What this study adds O_LITo address these concerns, this study re-estimates the ADI properly from source data to ensure that the final index reflects a combination of all 17 census measures, and not just home value and income. C_LIO_LIThe updated ADI more accurately reflects the distribution of deprivation in neighborhoods across the country and is highly correlated with life expectancy and age-specific mortality rates. C_LIO_LIThe updated ADI is available publicly and should be used by researchers who would like to utilize a broad measure of neighborhood deprivation. C_LI

IntroductionImproving the number of children who achieve a good level of development (GLD) on the Early Years Foundation Stage Profile (EYFSP) at the end of their first school year (aged five), and reducing the equity gap in this outcome was made a national priority in England in 2025. Children in England also receive a developmental assessment - the Ages and Stages Questionnaire-3 (ASQ-3) aged two. No study to date has explored the association between the ASQ-3 and EYFSP assessments. The aim of this study is to explore whether a GLD on the ASQ-3 is predictive of a GLD on the EYFSP using a longitudinal sample of children. MethodsLongitudinal pseudonymised data from the Connected Bradford dataset was used to undertake multiple regression analyses. ResultsFrom September 2013 to May 2025, 47,046 children had an ASQ-3 record, of whom 6,021 (13%) had a linked EYFSP record. Boys and children living in the lowest quintiles of the Index of Multiple Deprivation were less likely to achieve a GLD on both the ASQ-3 and the EYFSP. Children from South Asian ethnic groups were least likely to achieve a GLD on the ASQ-3, whilst White Other children were least likely to achieve a GLD on the EYFSP. Achieving a GLD on the ASQ-3 was predictive of a GLD on the EYFSP, with children who achieved a GLD on the ASQ-3 having more than three-times the odds of achieving a GLD on the EYFSP (OR 3.18, 95% CI 2.70 to 3.75). ConclusionThis study highlights the potential value of using the ASQ-3 results to intervene early and support more children to become school ready. These findings also show that many children have fallen behind by the age of two, thus emphasising the importance of intervening from the earliest possible moment to reduce inequities in child development. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIIn England, approximately 3 in 10 children do not reach a Good Level of Development (GLD) on the Early Years Foundation Stage Profile (EYFSP) which is undertaken at the end of the Reception year of school. Reaching a GLD is associated with later educational attainment. C_LI What this study addsO_LIThis study is the first to use longitudinal data to explore whether achieving a GLD on the developmental assessment undertaken at age 2 - the Ages and Stages Questionnaire 3 (ASQ-3), can predict the GLD on the EYFSP at school. C_LIO_LIThis study found that children who did not achieve a GLD on the ASQ-3 had three times the odds of not achieving a GLD on the EYFSP. Boys, those living in areas of high deprivation, and those from White Other backgrounds were also less likely. C_LI How this study might affect research, practice or policyO_LIThis study highlights the potential value of using the ASQ-3 results to intervene early and support more children to become school ready. These findings also show that many children have fallen behind by the age of two, thus emphasising the importance of intervening from the earliest possible moment to reduce inequities in child development. C_LI

The end-of-career stage of the police lifecycle represents a profound shift in identity and psychological stability, yet it remains historically neglected in research. This mixed-methods study investigated perspectives of UK police leavers and those approaching retirement (N = 325) regarding desired improvements to organisational support. Content analysis identified four themes: Holistic support and long-term welfare, Institutional culture and professional worth, Navigating the structural transition, and Individual and systemic perspectives. Findings suggest that the psychological contract between the officer and the organisation is often breached at the exit point, shifting from a relational bond to a transactional disposal. Middle-ranking officers and early leavers report the highest levels of institutional abandonment. To address these gaps, this paper makes recommendations for developing effective transitions. By implementing post-service welfare, and adopting structured resettlement models, police organisations can fulfil their duty of care and mend the psychological contract for those who have served.

ObjectiveThe study aimed to understand the perspectives of professionals from multi-agencies working with individuals experiencing homelessness with complex health and social circumstances (PHECHS), specifically focusing on how they define and contextualise the concept of "complex needs". Methodsixteen qualitative interviews with multi-agencies working with people experiencing homelessness were analysed using Heideggers interpretive phenomenological analysis (IPA), theories of socioeconomic determinants and international and national policy analysis were utilised to analyse data collected by MM on the multi-agency approach to individuals experiencing homelessness with complex health and social needs (PHECHS). FindingsThe analysis of a multi-agency approach aimed at supporting PHECHS revealed that complex needs arise gradually during childhood and can continue into adulthood. A range of factors contribute to both homelessness and these complex needs. Deconstructing the social and economic factors that underpin this continuum is essential to effectively addressing these challenges. This study conceptualises the complex needs of PHECHS into two key themes: deconstructing the PHECHS and attritional approach to PHECHS. ConclusionHomelessness is a grave human rights violation, depriving people of essentials like housing, food, health, education, and social participation. Governments have a moral and legal duty to end homelessness. Real progress demands comprehensive, sustained, and rights-based strategies that tackle root causes--poverty, trauma, and social exclusion. Homelessness also stems from gaps in vital life skills: job seeking, financial management, accessing services, and self-care. These barriers make it even harder to secure stable housing. Lasting reductions in homelessness result from a strong legislative framework, national guidelines, and sustained financial investment. Strengths and limitations of this study1. Employing qualitative methods and analysing data through the lens of socioeconomic determinants of health inequalities enabled the development of a model that clarifies the structural causes of homelessness and highlights key opportunities for preventive policy interventions. 2. Examining the data through the lens of socioeconomic health determinants reveals how systemic and structural factors, such as housing policy and service access, drive complex needs beyond individual circumstances. 3. The study was conducted in an affluent, demographically homogenous city, resulting in the underrepresentation of individuals from ethnic minority backgrounds, women, and young people. 4. Future research should investigate the experiences of people experiencing homelessness using an asset-based perspective, leveraging frameworks that emphasise resourcefulness to promote their meaningful engagement and inclusion in society.

Abstract Background Musculoskeletal conditions, such as back pain and osteoarthritis, are common and disabling disorders. Musculoskeletal conditions are closely related to chronic disease risk factors like smoking/vaping, poor nutrition, alcohol misuse and physical inactivity and impact a person's risk of falling (SNAPF). Preventive care for SNAPF risks is often overlooked. Online delivery of preventive care may increase the provision of this care. We aimed to assess if an online tool for SNAPF risks would be used by and acceptable to patients waiting for an orthopaedic consultation. Methods We completed a multi-method study to test an online health risk self-assessment tool. A random sample of 300 people on the orthopaedic outpatient waiting list aged 18-64 years were sent the tool in batches of 20-50. The tool assessed SNAPF risks and provided feedback against national guidelines. After each batch, we completed feedback interviews with participants to assess acceptability and updated the tool. We summarised quantitative data using descriptive statistics and qualitative data using thematic analysis. Results Of the 300 participants sent the tool, 51.3% were female, 8.6% identified as Aboriginal and/or Torres Strait Islander, with a mean (SD) age of 52.0 years (11.2). There were 170 participants (59.2%) who completed the tool, 117 who did not complete it, and 13 participants who were excluded from analysis because they did not receive the SMS. We conducted 184 feedback interviews, including 125 'completers' and 59 'non-completers'. The percentage of participants who felt that SMS was an appropriate way to receive the tool was 84.7% of 'completers' and 50% of 'non-completers'. The two most common reasons for not completing the tool were due to perceived risk (13/59, 22.0%), and the SMS was received at an inconvenient time (11/59, 18.6%). Qualitative data from the feedback interviews captured three enablers: i) design, ii) high importance, and iii) engagement with health service, along with four barriers: i) design, ii) risk, iii) relevance, and iv) engagement with health service. Conclusion Our study found that an online health risk self-assessment tool appears to be an acceptable way to assess chronic disease and falls risk factors for people on an orthopaedic waitlist.

ObjectivesTo quantify patterns of preventable death in Australian coronial findings, measure government compliance with coroner recommendations across jurisdictions, and identify case characteristics associated with recommendation issuance and acceptance. DesignCross-sectional computational text analysis of publicly available coronial findings using unsupervised topic modelling and rule-based classification. SettingAustralian coronial system, all eight state and territory jurisdictions, findings published on the Australasian Legal Information Institute (AustLII) database, 2000-2024. Participants9833 coronial findings and 2040 linked government responses. Main outcome measuresDeath-type topic prevalence, recommendation rate by jurisdiction, government response acceptance rate. ResultsTwenty-six death-type topics were identified, with medical/surgical deaths (12.5%), men-tal health (10.4%), and deaths in custody (8.6%) most prevalent. Overall, 45.6% of published find-ings contained formal recommendations (95% CI, 44.6-46.5%). Of 2040 government responses, 43.0% were unclassifiable (predominantly Victorian administrative cover letters). Among classifi-able responses, 53.2% were accepted (implemented, already implemented, or partially accepted), ranging from 26.0% (Western Australia) to 88.0% (Queensland). Multivariable logistic regression showed that jurisdiction was the strongest measured predictor of acceptance (pseudo R2 0.13 vs 0.14 with all covariates), though most variance remained unexplained. Among published findings, In-digenous Australians were represented in 10.1% (2.7 times the 3.8% population share).12 Findings involving medication errors had the highest recommendation rate (55.1%) but among the lowest acceptance rates (26.4%). ConclusionsAmong publicly available coronial findings, fewer than half contain formal recom-mendations. Government acceptance is low and structurally determined by jurisdiction rather than case characteristics, suggesting that legislative reform is needed to improve the systems preventive effectiveness.

BackgroundHelmet use is a proven safety measure that reduces the risk of head injury among cyclists and e-scooter riders. Despite legal requirements for pedal bikes and e-bikes in Australia, compliance varies, particularly among users of electric vehicles. The growing popularity of e-bikes and e-scooters in urban areas presents new public health challenges, yet observational data on helmet use, behavioural determinants, and the effectiveness of safety interventions remain limited. AimPhase 3 of the Helmet Use in Canberra study aims to characterise head injury presentations associated with cycling and e-scooter use and examine their association with helmet use and injury severity. MethodsDe-identified emergency department records from The Canberra Hospital will be retro-spectively analysed for presentations involving cycling or e-scooter-related head injuries during the study period. Extracted variables will include age, sex, vehicle type, documented helmet use, injury diagnosis, severity indicators, and date/time of presentation. Descriptive statistics will summarise injury patterns, while regression analyses will evaluate associations between helmet use and injury severity, controlling for demographic and contextual factors. Sensitivity analyses will address missing helmet data and subgroup differences by vehicle type, age, and gender. Expected ResultsIt is hypothesised that lower helmet use will correlate with higher rates and greater severity of head injury presentations. Findings will provide a population-level perspective on helmet effectiveness, inform local injury prevention strategies, and guide public safety interventions. Trial RegistrationAustralian and New Zealand Clinical Trials Registry (ANZCTR) [ACTRN12626000245392]

IntroductionThis article summarises lessons learnt from the Health Outcomes for young People throughout Education (HOPE) Study and serves as a real world, transferable application for addressing causal questions using administrative data. The HOPE study applied causal methods to analyses of administrative data in Education and Child Health Insights from Linked Data (ECHILD) aimed at studying the effectiveness of provision for special educational needs and disability (SEND) on health and education outcomes. MethodsDefining causal questions regarding the impact of SEND provision required judicious mapping of the question onto the data, leading to the selection of appropriate measures of effect, transparent handling of the data and control of confounding factors to estimate effects. We adopted the target trial emulation framework to guide these steps. Having encountered specific computational challenges in estimating the effects of interest, we simulated data that resembled the HOPE study and used them to practice the implementation of alternative estimation methods and to study impact of some of their assumptions. ResultsThe creation and analysis of the simulated data provided valuable insights. First, we learned the importance of aligning the target of estimation with the causal question at hand. Second, we observed how deviations from assumptions specific to each estimation method can affect results. Third, we highlighted the benefits of employing alternative estimation methods as sensitivity tools that can aid the interpretation of the resulting estimates. Finally, we offer user-friendly code in two programming languages (R and Stata) and accompanying simulated data to facilitate the implementation of these methods for similar causal questions. ConclusionWe recommend users of administrative data to fully specify -and possibly revise- the causal questions they wish to address and to carefully examine and compare assumptions, implementation and results obtained using alternative estimation methods.

Natural language processing was applied to 3,586 Australian health practitioner tribunal decisions (1999-2026) to identify patterns in professional misconduct, outcomes, and temporal trends at a scale impractical through manual analysis. A text classification approach categorised 2,428 disciplinary decisions across seven misconduct types with acceptable accuracy for the major categories (per-class F1 0.47-0.82). Boundary violations were the most prevalent misconduct type (30.2%), followed by dishonesty/fraud (29.7%) and professional conduct breaches (28.0%). Reprimand was the most common outcome (53.0%), followed by cancellation (40.2%). Significant increasing trends were identified for boundary violations, dishonesty/fraud, professional conduct breaches, and communication failures. Boundary violations were associated with higher cancellation odds (OR = 1.36, p < 0.001). Opioid medications appeared in 67% of prescribing misconduct decisions. Significant jurisdictional variation in both misconduct types and outcomes was observed, with large effect sizes between major jurisdictions. The findings provide an empirical foundation for monitoring disciplinary trends under the National Law.

IntroductionWith global populations ageing, demand for palliative care is increasing. Population-level assessments of unmet palliative care needs are essential for strategic planning, yet rigorous methods to estimate unmet needs are lacking. This study aimed to develop methods and estimate current and future population-level prevalence of unmet palliative care needs among adults in England and Wales. MethodsSecondary analyses of data from a nationally representative post-bereavement survey in England and Wales in 2022 (n=1,194). Unmet needs in the survey sample were estimated using two methods: (1) reported unresolved symptoms and concerns using Integrated Palliative care Outcome Scale scores, cutoff [&ge;]34/68; and (2) reported insufficient care provision from general practitioners. These methods were combined to further provide a conservative estimate (1 and 2) and a broad estimate (1 or 2). We examined associations with unmet needs using modified Poisson regression. Age-, gender- and nation-specific sample estimates were applied to mortality data for 2022 and projections from the Office for National Statistics to calculate population-level estimates and prevalence from 2025 to 2050. ResultsIn 2022, 247,993 (46%) adult decedents in England and 17,209 (49%) in Wales had unmet palliative care needs using method 1; 244,612 (46%) and 15,280 (43%), respectively, using method 2. According to conversative and broad estimates, 32% and 61% could have unmet needs in England, and 29% and 62% in Wales. By 2050, prevalence of unmet needs are projected to rise by 21-26% in England and 14-19% in Wales depending on estimate used, with the largest absolute increase among those aged [&ge;]85 years. ConclusionsUnmet palliative care needs are high in England and Wales and projected to increase by 2050, regardless of method. We contrast methods based on unresolved symptoms and concerns or insufficient care provision, or both, to inform the planning and evaluating of equitable care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIAlthough understanding population-level unmet palliative care needs is critical for effective service planning, robust and standardised methods to estimate these needs remain limited. C_LI What this study addsO_LIWe use two methods to provide four estimates of population-level prevalence of unmet palliative care needs and discuss their strengths and limitations. C_LIO_LIRegardless of estimate, prevalence of unmet palliative care needs is high, ranging 32-61% in England and in 29-62% in Wales; the number of people with unmet needs is anticipated to increase by 21-26% in England and 14-19% in Wales by 2050. C_LI How this study might affect research, practice or policyO_LIThis advancement in methods to estimate unmet palliative care needs can inform the development and evaluation of population-level strategies to improve end-of-life care. C_LIO_LIOur population-level estimates do not account for multiple long-term conditions which are rising and will likely increase the complexity of needs. C_LIO_LIThere needs to be more investment in primary and community-based services to ensure high-quality symptom management and support for people and their families towards the end of life. C_LI

BackgroundCommunity safety is a key determinant of mental well-being, yet racially and ethnically minoritised communities in the UK often face higher exposure to violence alongside barriers to formal protection and support. In these contexts, informal support networks may play a critical role in shaping how safety is experienced and how distress is managed. Although such networks are widely recognised as protective for mental well-being, there is limited qualitative research examining how they operate in relation to community safety in settings shaped by structural inequality. This study explores how informal support networks influence experiences of community safety and mental well-being among racially and ethnically minoritised groups in South East London. MethodsThis qualitative study draws on semi-structured interviews (n = 31) with racially and ethnically minoritised participants aged 16+ living or working in Lambeth and Southwark [South East London]. Using a co-produced qualitative design, community consultations informed the development of interview topics. Interviews explored informal support networks, experiences of community safety and their intersections with mental well-being. Audio-recorded interviews were transcribed verbatim and analysed using inductive thematic analysis. ResultsFour themes were identified: (1) experiences of community safety and their mental health impacts; (2) gendered experiences of safety and responsibility; (3) formal support and its barriers; and (4) community and peer-led initiatives as a response to institutional distrust. ConclusionInformal support networks are central to everyday safety and emotional well-being, yet they cannot substitute for adequately resourced, culturally informed public provisions. Strengthening public infrastructure must involve meaningful collaboration with trusted community networks and address the intersectional needs of racially and ethnically minoritised groups.

BackgroundHelmet use is a proven safety measure that reduces the risk of head injury among cyclists and e-scooter riders. Despite legal requirements for pedal bikes and e-bikes in Australia, compliance varies, particularly among users of electric vehicles. The growing popularity of e-bikes and e-scooters in urban areas presents new public health challenges, yet observational data on helmet use, behavioural determinants, and the effectiveness of safety interventions remain limited. AimPhase 4 of the Helmet Use in Canberra study aims to identify demographic and behavioural predictors of unsafe riding and to explore perceived barriers and facilitators to helmet use, including compliance with existing regulations. MethodsA cross-sectional survey will be administered to Canberra residents aged 18 years or older, both online and in-person. The survey will assess attitudes toward helmet use, perceptions of head injury risk, and the deterrent effect of fines. Data will capture demographic characteristics, vehicle type, riding behaviours under varying conditions, and opinions regarding mandatory helmet laws and signage interventions. Survey responses will be de-identified, securely stored, and analysed using descriptive statistics and ordinal logistic regression to evaluate factors influencing compliance. Survey findings will be triangulated with observational and hospital data from earlier study phases. Expected ResultsThe survey is anticipated to provide insights into public attitudes toward helmet use, the perceived effectiveness of fines as behavioural deterrents, and the acceptability of policy interventions. These findings will inform evidence-based strategies to improve helmet compliance and reduce head injuries among urban riders. Trial RegistrationAustralian and New Zealand Clinical Trials Registry (ANZCTR) [ACTRN12626000245392].

ObjectiveTo examine adherence to COVID-19 public health measures among culturally and linguistically diverse (CALD) and low socio-economic status (SES) populations in Victoria using a unique longitudinal cohort. Study DesignThe Optimise Study was a mixed-methods longitudinal cohort and social networks study (September 2020 - December 2023) assessing the impact of COVID-19 and related public health measures in Victoria, Australia. We used a serial cross-sectional design to analyse adherence to public health recommendations, restrictions, and requirements. Settings, participantsThe study examines two 28-day periods during the COVID-19 pandemic in Victoria: April 23- May 20, 2021 ( non-lockdown), and September 13-October 10, 2021 ( lockdown). We explored adherence to three categories of COVID-19 public health measures -- Recommendations (non-enforced, longer-term), Restrictions (mandated during lockdown periods), and Requirements (mandated, longer-term) -- among participants who completed questionnaires during these periods. Participants were grouped as: 1) non-CALD high SES (did not meet CALD or low-SES criteria), 2) CALD, or 3) non-CALD low-SES. Main outcome measuresPrimary outcomes were adherence to Recommendations, Restrictions, and Requirements during the two study periods. ResultsOf 782 participants recruited, 579 (75%) completed a survey or diary during at least one study period and were included in the analysis. Of these, 275 (47%) were in the non-CALD high-SES group, 114 (20%) in the CALD group, and 190 (33%) in the non-CALD low-SES group. Across all groups, risk-reduction behaviours increased during the lockdown. CALD participants showed higher adherence to some Recommendations and Restrictions compared to the other groups. Overall, 28% left home while awaiting a COVID-19 test result, commonly due to work. ConclusionsHigh adherence among CALD and non-CALD low-SES groups suggest structural barriers, rather than behavioural non-compliance, contributed to higher COVID-19 impacts, highlighting the need for tailored support. During future public health emergencies, better supports are needed for individuals working outside of home to remain in isolation while awaiting a test result. Summary box O_TEXTBOXWhat is already known about this subject? In Australia, priority populations such as culturally and linguistically diverse (CALD) and low socio-economic status (SES) groups experienced higher COVID-19 infection, mortality and a disproportionate impact from public health restrictions. What does this study add? CALD populations had an overall higher level of adherence to public health behavioural measures during both lockdown and non-lockdown periods compared to non-CALD populations. Over 25% of participants did not comply with stay-at-home requirements while awaiting a COVID-19 test result, largely due to work responsibilities. How might this impact on clinical practice? Pandemic preparedness efforts should focus on understanding the reasons for non-adherence with isolation requirements and considering tailored support during future pandemics to address the diverse C_TEXTBOX

In this article we argue that intersectoral collaboration is ultimately manifested at the neighbourhood level, where professionals from diverse sectors engage in a joint network to improve population health outcomes. To strengthen intersectoral collaboration in neighbourhoods with low SES, it is crucial to include the community voice, representing diverse citizens who must be heard and engaged in decision-making processes. This study aims to contribute to the literature of intersectoral collaboration by exploring how networks emerge and evolve over time. We focus on the development of the roles of citizens in the professional network and diverse sectoral involvement within a local network of the team called The Connectors, in a neighbourhood with low socioeconomic scores (SESs). Methodologically, we use a combination of social network analysis (SNA) and action research. Results show that the network expanded significantly over time, both in terms of the number of actors and the diversity of sectors involved. At both measurement points T1 and T2, the majority of collaborations occurred across sectoral boundaries. By the second measurement, the proportion of intersectoral relationships had increased. This indicates that as the network expanded, new collaborations were not confined to existing sectoral clusters but increasingly bridged different sectors. The dual role that citizens have taken on during the development of the network, serving both as community voice representatives and professionals, can be empowering, offering pathways for personal growth and career advancement. However, it also introduces complexity, as these individuals may experience tensions between personal commitments and professional responsibilities. To enable network development, policies should allow room beyond standard protocols and organizational silos, as well as provide sufficient time for relationships and structures to mature. Although network building is a gradual and complex process, once established, these networks can play a pivotal role in delivering integrated and responsive care.

Background: The two-child benefit cap, implemented in April 2017, restricted Universal Credit and Child Tax Credit to the first two children in households with three or more children. We evaluate the impact of the two-child benefit cap on parental mental, general, and financial health, as well as investigate how this may differ in particular sociodemographic and economic subgroups based on sex, ethnicity and income. Methods: Data was obtained from parents (youngest child aged 5 or under) in the UK Household Longitudinal Survey from 2009 to 2023. Outcomes included parental mental health (psychological distress and life satisfaction), general health (health-related quality of life (HRQoL), self-rated health and health satisfaction), and financial health (current financial situation and financial outlook). We used complementary policy evaluation methods with different strengths and assumptions to triangulate evidence and strengthen inference: interrupted time series (ITS), difference-in-differences (DiD) and controlled time series analysis (CITS). Subgroup analyses were stratified by sex, ethnicity, and income. Findings: Across methods, findings consistently indicate that the policy worsened life satisfaction, self-rated health, health satisfaction, and financial health for parents of 3+ children. Findings were less consistent across methods for psychological distress and HRQoL. For instance, for psychological distress ITS and CITS indicate adverse impacts of the policy; however, one DiD model did not support this conclusion due to greater average worsening in the control group between the pre- and post-periods. Subgroup analyses indicate greater mental health and general health impacts in lower income, male and ethnic minority parents; while financial health was negatively impacted in all subgroups examined. Conclusions: Using repeated cross-sectional panel data and triangulating across causal inference methods, we conclude that the two-child benefit cap in the UK had a measurable adverse impact on most health outcomes examined, with worse outcomes for male, lower income and ethnic minority parents.

Objectives: Longer lifespans lead to longer time on retirement, despite the efforts to raise the retirement age. Therefore, it is important to study how the retirement years can be spent without diseases. This study examined socioeconomic and sociodemographic differences in healthy years spent on retirement. Methods: We followed a cohort of retired Finnish municipal employees (N=4231, average follow-up 15.4 years) on national administrative registers for major chronic diseases: cancer, coronary heart disease, cerebrovascular disease, diabetes, asthma or chronic obstructive pulmonary disease, dementia, mental disorders, and alcohol-related disorders. Median healthy years on retirement and age at first occurrence of illness (ICD-10 and ATC-based) in each combination of sex, occupational class, and age of retirement were predicted using Royston-Parmar models. Prevalence rates for each diagnostic group were calculated. Results: Most healthy years on retirement were spent by women having worked in semi-professional jobs who retired at age 60-62 (median predicted healthy years 11.6, 95% CI 10.4-12.7). The least healthy years on retirement were spent by men having worked in routine non-manual jobs who retired after age 62 (median predicted healthy years 6.5, 95% CI 4.4-9.5). Diabetes was slightly more common among lower occupational class women, and dementia among manual working women having retired at age 60-62. Discussion: Healthy years on retirement are not enjoyed equally by women and men and those who retire early or later. Policies aiming to increase the retirement age should consider the effects of these gaps on retirees and the equitability of those effects.

BackgroundAvian Influenza (AI) is a potential pandemic threat, specifically when human-to-human transmission occurs. For outbreak management testing is essential. Current knowledge on testing behaviour is mostly derived from other infectious diseases such as COVID-19. It is necessary to identify determinants of testing behaviour for AI in an early phase. Therefore, this interview study aims to identify a wide range of behavioural determinants of testing during a hypothetical human-to-human transmissible AI outbreak. MethodsSemi-structured in-depth interviews, based on the Theoretical Domains Framework, were carried out between May 2024 and February 2025. Participants were included through purposive and convenience sampling. During the interviews an animation was shown illustrating a hypothetical AI outbreak. Verbatim transcripts were thematically analysed. ResultsWe included seventeen participants (median age 44, range 20-81; 71% women) with diverse backgrounds in terms of age, gender, educational level and country of birth. We found that having the freedom to decide to test would make testing more acceptable, whereas a decreased sense of autonomy would discourage testing. Most themes included individual rather than population-level benefits as drivers of testing behaviour. These included protecting loved ones, ones own health and gaining psychological reassurance. External conditions like being unable to go to work or an event would generally encourage testing behaviour. Lower trust in governmental authorities could hamper testing behaviour. Previous experiences from the COVID-19 pandemic shaped participants answers about AI testing behaviour. ConclusionKey considerations include balancing peoples need for autonomy with the external measures imposed by employers or the government, rebuilding trust in institutions and acknowledging how prior experiences with testing may shape testing behaviour in future AI outbreaks. Further research is needed to determine how these findings can be translated into effective communication and how trust in authorities can be build.

BackgroundWorking while sick (presenteeism) with an infectious disease contributes to the spread of infections and is detrimental to productivity. Respiratory illnesses are a common cause of sickness in the working population and understanding the prevalence of presenteeism linked to respiratory illness is therefore important. MethodsWinter Covid Infection Study (WCIS) panel members in work aged 18-64 were surveyed in February - March 2024 and asked about presenteeism in the previous 28 days. Multilevel regression and poststratification was used to estimate the prevalence and length of presenteeism and its effect on productivity in the English workforce, as approximated using the WCIS survey sample calibrated to census proportions. Differences by demographic groups and work sector were also analysed. ResultsAround one in six working adults in England worked while sick with a respiratory infection during the study period, and one in ten attended a non-home workplace. Overall, around one day per adult was spent working while sick with a respiratory infection, approximately half of which was non-home working. Respondents felt they were able to work at around three-quarters of their usual capacity while sick. Presenteeism was more common among respondents who were younger, White, worked in a hybrid pattern, lived in larger households, had Long COVID-19, or worked in teaching and education. ConclusionWorking while sick with a respiratory infection is relatively common, including among those who primarily work away from the home. Key messagesAround one in six working-age adults in employment worked while sick with a respiratory infection during the study period (Feb-Mar 2024). - The likelihood of working while sick with a respiratory infection varied by demographic group and work sector. - On average, survey respondents said they could work at around three quarters their normal effectiveness while sick with a respiratory infection.

Background Parenting practices shape children's emotional, social, and cognitive developmental wellbeing. Yet, many families face complex challenges that increase the risk of poor outcomes and demand on social care. The Sutton Parenting Offer (SPO) is a universal, peer-led parenting offer that provides early, non-stigmatising support to families with children aged 0-25 years. It combines evidence-based programmes with informal workshops and peer networks delivered through Family Hubs. This present study is an evaluation protocol of the parenting offer. Aim This evaluation aims to explore how, why, and in what contexts SPO supports families in engaging, sustaining positive change, and generating wider system value. Methods A mixed-methods realist evaluation approach will be used to evaluate SPO across four work packages: engagement pathways, early changes and peer-led ecosystems, long-term change, and system value for money. Data sources will include attendance data (anonymised service records), survey data (entry and exit), and qualitative data (dyad interviews, story circles, and stakeholder-value mapping workshops). The COM-B and the Theoretical Domains Framework (TDF) will guide the analysis of behavioural data. Quantitative data will be analysed descriptively and using paired parametric and non-parametric tests, while qualitative data will be analysed thematically following a realist-informed approach to refine context-mechanism-outcome (CMO) configurations. Discussion This protocol presents the first realist informed evaluation of a universal parenting program in a local authority setting. The evaluation will generate evidence on how, when and why a universal, community-based, and peer-led model such as the Sutton Parenting Offer engages families and generates change. The findings will be useful to inform future parenting service design and implementation in local contexts in England.