James White | Cardiff University (original) (raw)

Books by James White

Papers by James White

International Journal of Epidemiology, 2021

Background: Homelessness encompasses a wide spectrum of experience. Rough sleepers and people at... more Background:
Homelessness encompasses a wide spectrum of experience. Rough sleepers and people attending homeless shelters have been found to be at an increased risk of mortality. It is unclear whether risks are also elevated in those squatting, living temporarily in low-cost hotels or 'sofa-surfing' with friends or family members. This study examines mortality in a representative nationwide sample of people who have slept rough, squatted, lived in shelters or low-cost hotels and sofa-surfed.

Methods: Using unpublished data from two national birth cohorts, namely the National Child Development Study and the 1970 British Birth Cohort study, Cox proportionalhazards models and random-effects meta-analyses were used to analyse associations between homelessness and different types of homeless experience (rough sleeping, squatting, staying in a homeless shelter or low-cost hotel, and sofa-surfing) and mortality.

Results: Out of the 23 678 participants, 1444 (6.1%) reported having been homeless and 805 (3.4%) deaths occurred. Homelessness was associated with an increased risk of mortality [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.24-2.26]. Mortality risk was raised across the spectrum of homeless experience, from sleeping rough (HR 4.71, 95% CI 2.38-9.30), to squatting (HR 6.35, 95% CI 2.73-14.75), staying in a homeless shelter (HR 4.89, 95% CI 2.36-10.11), staying in a low-cost hotel (HR 3.38, 95% CI 1.30-8.79 through to sofa-surfing (HR 2.86, 95% CI 1.84-4.42). Associations remained after separate control for socioeconomic status, mental health, substance use, accidents and assaults, and criminality.

Conclusions: Mortality rates were raised across all types of homeless experience. This included squatting and sofa-surfing that have not previously been reported. Studies that have omitted the less severe, but more prevalent, use of low-cost hotels and sofa-surfing may have underestimated the impacts of homelessness on mortality.

Journal of Epidemiology and Community Health, 2021

Background Homelessness has been linked to premature mortality but the relationship with biomedic... more Background Homelessness has been linked to premature mortality but the relationship with biomedical risk factors is uncertain.

Methods We analysed data from 8,581 participants in the 1970 British Birth Cohort Study. Homelessness and type of experience were self-reported at 30 years of age. Nine biomarkers outcomes were collected at 46 years of age: body mass index (BMI), blood pressure, total and high-density cholesterol, triglycerides, glycated haemoglobin, C-reactive protein (CRP), insulin-like growth factor 1, and we computed the 10-year risk for coronary heart disease.

Results By 30 years of age, 5.8% of participants had been homeless with sofa surfing the most common experience (4.3%). Homelessness was associated with socioeconomic disadvantage, mental health problems and substance use in early adulthood, but these differences were not expressed in biomarkers. After accounting for early adulthood characteristics, residing in a bed and breakfast was associated with a higher BMI (0.59, 95% CI 0.13 to 1.05) and C-reactive protein (0.16, 0.04 to 0.29), squatting with a lower BMI (-1.69, -3.08 to -0.21), and rough sleeping with a higher 10-year risk of coronary heart disease (0.03, 0.01 to 0.05).

Conclusions Exposure to homelessness in early adulthood was essentially unrelated to biomarkers in middle-age. Inconsistent links were found for specific types of experience.

Background Engagement in multiple risk behaviours can have adverse consequences for health during... more Background
Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in
life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young
people, or the differential impact of universal versus targeted approaches. Findings fromsystematic reviews have beenmixed, and effects
of these interventions have not been quantitatively estimated.
Objectives
To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk
behaviours among young people.
Search methods
We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing
and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library;
Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO;
and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists,
contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.
Selection criteria
We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours.
Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed
to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected
from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months
or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We
categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.
Data collection and analysis
We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review
authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.
We pooled data inmeta-analyses using a random-effects (DerSimonian and Laird)model inRevMan 5.3. For each outcome,we included
subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at
up to 12 months’ follow-up and over the longer term (> 12 months).We assessed the quality and certainty of evidence using the Grades
of Recommendation, Assessment, Development and Evaluation (GRADE) approach.
Main results
We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28;
40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours.
Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53),
followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.
Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds
ratio (OR) 0.77, 95%confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95%CI 0.56
to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may
be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and
engagement in any antisocial behaviour (OR 0.81, 95%CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence)
at up to 12 months’ follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderatequality
evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity
(OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health
importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions
for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence),
sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence),
and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence).
It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk
behaviours.
For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests
little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4
studies for each outcome).
Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants
receiving the intervention compared to participants given control interventions.
We judged the quality of evidence to bemoderate or low formost outcomes, primarily owing to concerns around selection, performance,
and detection bias and heterogeneity between studies.
Authors’ conclusions
Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they
may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving
physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence
of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around
the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the
evidence base in this field.

Objectives To examine whether young peoples’ risk of cannabis, mephedrone and novel psychoactive ... more Objectives To examine whether young peoples’ risk of
cannabis, mephedrone and novel psychoactive substances
(NPS) use is associated with school substance-misuse
policy.

Design A cross-sectional survey of secondary
school students combined with a School Environment
Questionnaire and independently coded school substancemisuse
policies (2015/6).

Setting 66 secondary schools in Wales.

Participants Students aged 11–16 years (n=18 939).
Results The prevalence of lifetime, past 30-day and daily
cannabis use was 4.8%, 2.6% and 0.7%, respectively;
lifetime prevalence of mephedrone use was 1.1% and
NPS use was 1.5%. Across 66 schools, 95.5% (n=63)
reported having a substance-misuse policy, 93.9% (n=62)
reported having a referral pathway for drug using students,
such that we were insufficiently powered to undertake an
analysis. We found little evidence of a beneficial association
between lifetime cannabis use and involving students in
policy development including student council consultation
(OR=1.24, 95% CI 0.89 to 1.73), other student consultation
(OR=1.42, 95% CI 0.94 to 2.14) or with the use of isolation
(OR=0.98, 95% CI 0.67 to 1.43), with similar results
for cannabis use in past 30 days, daily and the lifetime
use of mephedrone and NPS. The School Environment
Questionnaires found that 39.4% (n=26) schools reported
no student involvement in policy development, 42.4%
(n=28) reported student council consultation, 18.2%
(n=12) used other student consultations and 9.7% (n=3)
mentioned isolation. The independently coded content
of policies found that no school policy recommended
abstinence, one mentioned methods on harm minimisation,
16.1% (n=5) policies mentioned student involvement and
9.7% (n=3) mentioned isolation.

Conclusions Policy development involving students
is widely recommended, but we found no beneficial
associations between student involvement in policy
development and student drug use. This paper has
highlighted the need for further contextual understanding
around the policy-development process and how schools
manage drug misuse.

Introduction Teenage pregnancy remains a worldwide health concern which is an outcome of, and co... more Introduction
Teenage pregnancy remains a worldwide
health concern which is an outcome of, and contributor
to, health inequalities. The need for gender-aware
interventions with a focus on males in addressing teenage
pregnancy has been highlighted as a global health need by
WHO and identified in systematic reviews of (relationship
and sexuality education (RSE)). This study aims to test
the effectiveness of an interactive film-based RSE
intervention, which draws explicit attention to the role of
males in preventing an unintended pregnancy by reducing
unprotected heterosexual teenage sex among males and
females under age 16 years.

Methods and analysis
A phase III cluster randomised
trial with embedded process and economic evaluations. If
I Were Jack encompasses a culturally sensitive interactive
film, classroom materials, a teacher-trainer session and
parent animations and will be delivered to replace some
of the usual RSE for the target age group in schools in
the intervention group. Schools in the control group will
not receive the intervention and will continue with usual
RSE. Participants will not be blinded to allocation. Schools
are the unit of randomisation stratified per country and
socioeconomic status. We aim to recruit 66 UK schools
(24 in Northern Ireland; 14 in each of England, Scotland
and Wales), including approximately 7900 pupils. A
questionnaire will be administered at baseline and at
12–14 months postintervention. The primary outcome is
reported unprotected sex, a surrogate measure associated
with unintended teenage pregnancy. Secondary outcomes
include knowledge, attitudes, skills and intentions relating
to avoiding teenage pregnancy in addition to frequency of
engagement in sexual intercourse, contraception use and
diagnosis of sexually transmitted infections.

Ethics and dissemination
Ethical approval was
obtained from Queen’s University Belfast. Results will be
published in peer-reviewed journals and disseminated to
stakeholders. Funding is from the National Institute for
Health Research

PLOS One, 2018

Background Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 a... more Background

Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 and it is estimated that approximately 50% of the fall was due to improved treatment uptake. Marked socio-economic inequalities in CHD mortality in the United Kingdom (UK) remain,
with higher age-adjusted rates in more deprived groups. Inequalities in the persistence of medication for primary and secondary prevention of CHD may contribute to the observed social gradient and we investigated this possibility in the population of Wales (UK).

Methods and findings
An electronic cohort of individuals aged over 20 (n = 1,199,342) in Wales (UK) was formed using linked data from primary and secondary care and followed for six years (2004±2010). We identified indications for medication (statins, aspirin, ACE inhibitors, clopidogrel) recommended in UK National Institute for Clinical Excellence (NICE) guidance
for CHD (high risk, stable angina, stable angina plus diabetes, unstable angina, and myocardial infarction) and measured the persistence of indicated medication (time from initiation to discontinuation) across quintiles of the Welsh Index of Multiple Deprivation, an area-based measure of socio-economic inequality, using Cox regression
frailty models. In models adjusted for demographic factors, CHD risk and comorbidities across 15 comparisons for persistence of the medications, none favoured the least deprived quintile, two favoured the most deprived quintile and 13 showed no significant differences.

Conclusions
During our study period (2004±2010) we found no significant evidence of socio-economic inequality in the persistence of recommended medication for primary and secondary prevention of CHD.

Journal of Epidemiology and Community Health

Background: To examine the combined influence of changes in physical activity, diet, smoking, and... more Background: To examine the combined influence of changes in physical activity, diet, smoking, and alcohol consumption on all-cause mortality.
Methods: Health behaviors were assessed in 1984/5 and 1991/2 in 8,123 adults from the United Kingdom (4,666 women, median age, 41.0 years). An unhealthy lifestyle score was calculated, allocating one point for smoking, fruits and vegetables < 3 times a day, physical activity < 2 hours a week, and > 14 units (women) or >21 units of alcohol (men) per week.
Results: There were 2,003 deaths over a median follow-up of 6.6 years (interquartile range, 5.9, 7.2) following the resurvey. The modal change in the unhealthy lifestyle score was zero, 41.8% had the same score, 35.5% decreased, and 22.7% increased score between surveys. A one unit decrease in the unhealthy lifestyle score was not associated with a beneficial effect on mortality (hazard ratio (HR) = 0.93; 95% confidence interval (CI) = 0.83, 1.04). A one unit increase in the unhealthy lifestyle score increased the risk of mortality (adjusted HR = 1.09; 95% CI = 1.01, 1.18).
Conclusions: In this general population sample, the adoption of an unhealthy lifestyle was associated with an increased risk of mortality.

Epidemiology

To the Editor: Smoking, excess alcohol intake, physical inactivity, and low fruit and vegetable c... more To the Editor:
Smoking, excess alcohol intake, physical inactivity, and low fruit and vegetable consumption, are well-documented risk factors for mortality.1-4 Very few studies have, however, examined the association between changes in these behaviors and future mortality. Randomized trials have found smoking cessation reduces mortality risk.1 Observational studies suggest changes in physical activity are associated with mortality risk,2 but for fruit and vegetable and alcohol consumption the evidence is mixed. 3, 4 These studies have also examined changes in isolation but unhealthy changes in behavior may offset any beneficial effects accrued from healthy changes. For instance, smoking cessation is associated with around 4.7 kgs (10.4 lbs) weight gain after 12 months,5 and reductions in caloric intake may be compensated by concomitant reductions in physical activity.6 This study examined the associations of both healthy and unhealthy changes in behavior with the risk of all-cause mortality.

We used data from the Health and Lifestyle Survey I (1984/5) and II (1991-1992), a prospective cohort of residents in England, Wales, and Scotland aged ≥18 years in 1984. The study was approved by local ethics committees. An interviewer assessed participants’ current smoking status, alcohol consumption (≥ 14 per week for women/ ≥21 units for men), physical activity (≥2 hours a week), and fruit and vegetables consumption (≥ 3 times a day over the past year). Healthy and unhealthy changes between survey I and II were coded. We compared rates of mortality from all-causes between people making healthy and unhealthy changes using Cox proportional hazards models adjusted for other changes in behaviors, demographics, occupational social class (including an unemployed category) and physical health conditions. We imputed missing data using multiple imputation to generate 10 data-sets. We checked the proportional hazards assumption for Cox models using Schoenfeld residuals and found it was unviolated. Analyses were done using Stata (StataCorp), version 13.0.

Of the 9,003 baseline participants (74% of those recruited in survey I), 5,352 (59%) also took part in survey II. We excluded study members who had died between surveys (n= 880), resulting in an analytical sample of 8,123 (4,666 women, median age, 41 years [interquartile range, 30-56] with 2,003 deaths occurring over a median follow-up of 7 years [interquartile range, 6-7]) (Table). The risk of mortality was associated with increases (model 2 hazard ratio [HR] = 0.9, 95% confidence interval [CI] = 0.8-1.0) and decreases (model 2 HR = 1.1, 95% CI: 0.9-1.3) in physical activity, and reductions in fruit and vegetable consumption (model 2 HR = 1.3, 95% CI = 1.0-1.7). Changes in smoking status and alcohol consumption were not related to mortality rates. Sensitivity analyses in samples excluding people with missing data (n = 3,163), physical illness (n = 6,753), who died within five years of 1991/2 (n = 7,350) and with minimal adjustments produced the same pattern of results (eTables 1 to 4).

In this study, changes in physical activity and decreases in fruit and vegetable consumption were weakly associated with all-cause mortality. These findings confirm those from smaller studies suggesting modest increases in physical activity are associated with a 30%-40% reduction in mortality 2 and are in agreement with the PREDIMED trial which found decreases in mortality after increases in fruit consumption.3 We found no clear association between changes in smoking status or alcohol consumption with mortality risk. The benefits of smoking cessation have generally been found in populations older than those in the present study.1 Limitations of our work include misclassification of participants if behaviors changed after survey II and survivor bias whereby more healthy participants survived until the resurvey and were included, which may have underestimated associations. These observational data do not provide evidence of causality.

Suicide in children and young people is a major public health concern. However, it is unknown whe... more Suicide in children and young people is a major public health concern. However, it is unknown whether individuals who have been in the care of the child welfare system are at an elevated risk. Care is presently defined as statutory provision of supported in-home care or out-of-home care (e.g. foster care, residential care and kinship care). The present paper presents a systematic review and meta-analysis comparing the prevalence of suicidal ideation, suicide attempt and suicide in children and young people placed in with non-care populations. A systematic search was conducted of 14 electronic bibliographic databases and 32 websites. Of 2811 unique articles identified, five studies published between 2001 and 2011 met the inclusion criteria. Studies reported on 2448 incidents of suicidal ideation, 3456 attempted suicides and 250 suicides. The estimated prevalence of suicidal ideation was 24.7% in children and young people in care compared to 11.4% in non-care populations. The prevalence of suicide attempt was 3.6% compared to 0.8%. Two studies reported on suicide. Suicide risk in children and young people in care was lower in one study (0% vs 0.9%) and higher in the second (0.27% vs 0.06%).The results of the systematic review and meta-analysis confirm that suicide attempts are more than three times as likely in children and young people placed in the care compared to non-care populations. Targeted interventions to prevent or reduce suicide attempt in this population may be required. Further comparative studies are needed to establish if children and young people in care are at an elevated risk of suicidal ideation and suicide.

Background: Existing guidance for developing public health interventions does not provide informa... more Background: Existing guidance for developing public health interventions does not provide information for researchers about how to work with intervention providers to co-produce and prototype the content and delivery of new interventions prior to evaluation. The ASSIST + Frank study aimed to adapt an existing effective peer-led smoking prevention intervention (ASSIST), integrating new content from the UK drug education resource Talk to Frank (www.talktofrank.com) to co-produce two new school-based peer-led drug prevention interventions. A three-stage framework was tested to adapt and develop intervention content and delivery methods in collaboration with key stakeholders to facilitate implementation.

Neighborhood-level interventions provide an opportunity to better understand the impact of neighb... more Neighborhood-level interventions provide an opportunity to better understand the impact of neighborhoods on health. In 2001, the Welsh Government, United Kingdom, funded Communities First, a program of neighborhood regeneration delivered to the 100 most deprived of the 881 electoral wards in Wales. In this study, the authors examined the association between neighborhood regeneration and mental health. Information on regeneration activities in 35 intervention areas (n = 4,197 subjects) and 75 control areas (n = 6,695 subjects) were linked to data on mental health from a cohort study with assessments in 2001 (before regeneration) and 2008 (after regeneration). Propensity score matching was used to estimate the change in mental health in intervention versus control neighborhoods. Baseline differences between intervention and control areas were of a similar magnitude as produced by paired randomization of neighborhoods. Regeneration was associated with an improvement in the mental health of residents in intervention areas compared to control neighborhoods (β coefficient = 1.54, 95% confidence interval: 0.50, 2.59), suggesting a reduction in socioeconomic inequalities in mental health. There was a dose response relationship between length of residence in regeneration neighborhoods and improvements in mental health (P-for-trend = 0.05). These results show the targeted regeneration of deprived neighborhoods can improve mental health.

Assessments of socioeconomic position (SEP) and relative deprivation are important to many areas ... more Assessments of socioeconomic position (SEP) and relative deprivation are important to many areas of child and adolescent research. These related constructs are typically measured using data on household income or parental education or occupation. However, because such data can be difficult to collect in youth surveys, the World Health Organisation's Health Behaviour in School-aged Children (HBSC) study uses an inventory of common material assets in the home. The HBSC Family Affluence Scale is used to measure socioeconomic conditions in 11-to 15-year-olds in over 40 countries. This article examines the importance of SEP and relative deprivation to adolescent health and demonstrates simple calculations of these variables using the data from the Family Affluence Scale. We show how to transform a summation of material assets to a SEP index and apply Yitzhaki's (1979) index of relative deprivation to material assets using schoolmates as a social comparison group. These calculations are useful to investigating the contextual determinants of health and developmental inequalities in young people and can be modified for other socioeconomic variables in and populations.

Background Despite substantial falls in coronary heart disease (CHD) mortality in the United Kin... more Background

Despite substantial falls in coronary heart disease (CHD) mortality in the United Kingdom (UK), marked socioeconomic inequalities in CHD risk factors and CHD mortality persist. We investigated whether inequity in CHD healthcare in Wales (UK) could contribute to the observed social gradient in CHD mortality.
Methods and findings

Linking data from primary and secondary care we constructed an electronic cohort of individuals (n = 1199342) with six year follow-up, 2004–2010. We identified indications for recommended CHD interventions, measured time to their delivery, and estimated risk of receiving the interventions for each of five ordered deprivation groups using a time-to-event approach with Cox regression frailty models. Interventions in primary and secondary prevention included risk-factor measurement, smoking management, statins and antihypertensive therapy, and in established CHD included medication and revascularization. For primary prevention, five of the 11 models favoured the more deprived and one favoured the less deprived. For medication in secondary prevention and established CHD, one of the 15 models favoured the more deprived and one the less deprived. In relation to revascularization, six of the 12 models favoured the less deprived and none favoured the more deprived–this evidence of inequity exemplified by a hazard ratio for revascularization in stable angina of 0.79 (95% confidence interval 0.68, 0.92). The main study limitation is the possibility of under-ascertainment or misclassification of clinical indications and treatment from variability in coding.
Conclusions

Primary care components of CHD healthcare were equitably delivered. Evidence of inequity was found for revascularization procedures, although this inequity is likely to have only a modest effect on social gradients in CHD mortality. Policymakers should focus on reducing inequalities in CHD risk factors, particularly smoking, as these, rather than inequity in healthcare, are likely to be key drivers of inequalities in CHD mortality.

Elevated levels of inflammatory markers, such as C-reactive protein, are well documented in peopl... more Elevated levels of inflammatory markers, such as C-reactive protein, are well documented in people with depression. Few studies have examined whether the association between inflammation and depression is symptom specific, and differs according to antidepressant treatment. Using data from the English Longitudinal Study of Ageing (N = 5 909), crosssectional analyses revealed a significant dose-response association between C-reactive protein and the symptoms of fatigue (P < 0.001), restless sleep (P = 0.03), low energy (P = 0.02) and feeling depressed (P = 0.04), but not other symptoms. These associations were absent in users of anti-depressant medication. Our findings suggest the C-reactive proteindepression association is symptom-specific and modified by antidepressant treatment.

Introduction Systematic reviews have identified the lack of intervention studies with young chil... more Introduction

Systematic reviews have identified the lack of intervention studies with young children to prevent obesity. This feasibility study examines the feasibility and acceptability of adapting the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) intervention in the UK to inform a full-scale trial.

Methods and analysis
A feasibility cluster randomised controlled trial in 12 nurseries in England, with 6 randomly assigned to the adapted NAP SACC UK intervention: nursery staff will receive training and support from an NAP SACC UK Partner to review the nursery environment (nutrition, physical activity, sedentary behaviours and oral health) and set goals for making changes. Parents will be invited to participate in a digital media-based home component to set goals for making changes in the home. As this is a feasibility study, the sample size was not based on a power calculation but will indicate the likely response rates and intracluster correlations. Measures will be assessed at baseline and 8–10 months later. We will estimate the recruitment rate of nurseries and children and adherence to the intervention and data. Nursery measurements will include the Environmental Policy Assessment and Observation score and the nursery staff's review of the nursery environment. Child measurements will include height and weight to calculate z-score body mass index (zBMI), accelerometer-determined minutes of moderate-to-vigorous physical activity per day and sedentary time, and diet using the Child and Diet Evaluation Tool. Questionnaires with nursery staff and parents will measure mediators. A process evaluation will assess fidelity of intervention delivery and views of participants.

Ethics and dissemination
Ethical approval for this study was given by Wales 3 NHS Research Ethics Committee. Findings will be made available through publication in peer-reviewed journals, at conferences and to participants via the University of Bristol website. Data will be available from the University of Bristol Research Data Repository.

Trial registration number ISRCTN16287377

White et al 1 examined the relationship between the duration of depressive symptoms and mortality... more White et al 1 examined the relationship between the duration of depressive symptoms and mortality in adults aged 50 or older in a follow-up study. The authors assessed depressive symptom duration as the sum of screen-positive number by an eight-item Center for Epidemiologic Studies Depression Scale (CES-D) score of 53. Adjusted hazard ratios (HRs) and 95% confidence inter-Correspondence

Background Excess alcohol consumption has serious adverse effects on health and results in violen... more Background
Excess alcohol consumption has serious adverse effects on health and results in violence-related harm.

Objective
This study investigated the impact of change in community alcohol availability on alcohol consumption and alcohol-related harms to health, assessing the effect of population migration and small-area deprivation.

Design
A natural experiment of change in alcohol outlet density between 2006 and 2011 measured at census Lower Layer Super Output Area level using observational record-linked data.

Setting
Wales, UK; population of 2.5 million aged ≥ 16 years.
Outcome measures

Alcohol consumption, alcohol-related hospital admissions, accident and emergency (A&E) department attendances from midnight to 06.00 and violent crime against the person.

Data sources
Licensing Act 2003 [Great Britain. Licensing Act 2003. London: The Stationery Office; 2003. URL: www.legislation.gov.uk/ukpga/2003/17/contents (accessed 8 June 2015)] data on alcohol outlets held by the 22 local authorities in Wales, alcohol consumption data from annual Welsh Health Surveys 2008–12, hospital admission data 2006–11 from the Patient Episode Database for Wales (PEDW) and A&E attendance data 2009–11 were anonymously record linked to the Welsh Demographic Service age–sex register within the Secure Anonymised Information Linkage Databank. A final data source was recorded crime 2008–11 from the four police forces in Wales.

Methods
Outlet density was estimated (1) as the number of outlets per capita for the 2006 static population and the per quarterly updated population to assess the impact of population migration and (2) using new methods of network analysis of distances between each household and alcohol outlets within 10 minutes of walking and driving. Alcohol availability was measured by three variables: (1) the previous quarterly value; (2) positive and negative change over the preceding five quarters; and (3) volatility, a measure of absolute quarterly changes during the preceding five quarters. Longitudinal statistical analysis used multilevel Poisson models of consumption and Geographically Weighted Regression (GWR) spatial models of binge drinking, Cox regression models of hospital admissions and A&E attendance and GWR models of violent crime against the person, each as a function of alcohol availability adjusting for confounding variables. The impact on health inequalities was investigated by stratifying models within quintiles of the Welsh Index of Multiple Deprivation.

Results
The main finding was that change in walking outlet density was associated with alcohol-related harms: consumption, hospital admissions and violent crime against the person each tracked the quarterly changes in outlet density. Alcohol-related A&E attendances were not clinically coded and the association was less conclusive. In general, social deprivation was strongly associated with the outcome measures but did not substantially modify the associations between the outcomes and alcohol availability. We found no evidence for an important effect of population migration.

Limitations
Limitations included the absence of any standardised methods of alcohol outlet data collation, processing and validation, and incomplete data on on-sales and off-sales. We were dependent on the quality of clinical coding and administrative records and could not identify alcohol-related attendances in the A&E data set.

Conclusion
This complex interdisciplinary study found that important alcohol-related harms were associated with change in alcohol outlet density. Future work recommendations include defining a research standard for recording outlet data and classification of outlet type, the methodological development of residence-based density measures and a health economic analysis of model-predicted harms.

International Journal of Epidemiology, 2021

Journal of Epidemiology and Community Health, 2021

Conclusions Exposure to homelessness in early adulthood was essentially unrelated to biomarkers in middle-age. Inconsistent links were found for specific types of experience.

Design A cross-sectional survey of secondary
school students combined with a School Environment
Questionnaire and independently coded school substancemisuse
policies (2015/6).

Setting 66 secondary schools in Wales.

PLOS One, 2018

Background Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 a... more Background

Journal of Epidemiology and Community Health

Epidemiology

Background Despite substantial falls in coronary heart disease (CHD) mortality in the United Kin... more Background

Introduction Systematic reviews have identified the lack of intervention studies with young chil... more Introduction

Trial registration number ISRCTN16287377

Design
A natural experiment of change in alcohol outlet density between 2006 and 2011 measured at census Lower Layer Super Output Area level using observational record-linked data.

Setting
Wales, UK; population of 2.5 million aged ≥ 16 years.
Outcome measures

Alcohol consumption, alcohol-related hospital admissions, accident and emergency (A&E) department attendances from midnight to 06.00 and violent crime against the person.

Research on socioeconomic differences in overweight and obesity and on the ecological association... more Research on socioeconomic differences in overweight and obesity and on the ecological association between income inequality and obesity prevalence suggests that relative deprivation may contribute to lifestyle risk factors for obesity independently of absolute affluence. We tested this hypothesis using data on 25,980 adolescents (11–15 years) in the 2010 Canadian Health Behaviour in School-aged Children (HBSC) study. The Yitzhaki index of relative deprivation was applied to the HBSC Family Affluence Scale, an index of common material assets, with more affluent schoolmates representing the comparative reference group. Regression analysis tested the associations between relative deprivation and four obesity risk factors (skipping breakfasts, physical activity, and healthful and unhealthful food choices) plus dietary restraint. Relative deprivation uniquely related to skipping breakfasts, less physical activity, fewer healthful food choices (e.g., fruits, vegetables, whole grain breads), and a lower likelihood of dieting to lose weight. Consistent with Runciman's (1966) theory of relative deprivation and with psychosocial interpretations of the health consequences of income inequality, the results indicate that having mostly better off schoolmates can contribute to poorer health behaviours independently of school-level affluence and subjective social status. We discuss the implications of these findings for understanding the social origins of obesity and targeting health interventions.

Introduction The Family Nurse Partnership(FNP) is an intensive homevisiting service for teenage f... more Introduction
The Family Nurse Partnership(FNP) is an intensive homevisiting
service for teenage first-time mothers (and children),
developed/trialled in the US and adapted/trialled across Europe.
The Scottish Government(SG) aims to build on and supplement
the existing national/international evidence base for
FNP, to assess effectiveness and opportunities for optimisation
of the programme, for future decision making in Scotland.
Objectives and Approach
The evaluation commissioned is a natural experiment of FNP,
taking advantage of the existing information infrastructure in
Scotland. This natural experiment represents an important
opportunity to determine programme impact upon many key
programme outcomes using routinely collected data at a lower
cost than a comparably sized effectiveness trial. Key objectives
are: to identify clients in receipt of FNP-support and a control
sample of matched families who would meet criteria for FNP
but did not receive support, to obtain approval and through
anonymised data linkage link to health and other data, and to
determine the effect of FNP across a range of maternal and
child outcomes.
Results
The succes of the natural experiment design in trying to replicate
the gold standard design of the RCT will be presented and
will cover the following topics: (how cases and a comparable
group of first-time teenage women have been identified across
10 Health Boards (HBs) between 2009 and 2016 using data
made available by the electronic Data Research and Innovation
Service (eDRIS) from FNP, NHS Scotland and SG; the
matching process of the cases and controls using propensity
score methods to ensure an unbiased comparison; the linkage
to health, social care and educational datasets and the approval
processes involved, and the strengths and limitations of
using routine data to evaluate relevant study outcomes that
map to a logic model.
Conclusion/Implications
The impact of this evaluation into the effectiveness of FNP
in Scotland will establish a robustly matched study cohort, a
more strealmined linkage and approval process, and identification
of outcomes not only for a short-term follow-up but also
for a longer-term follow-up of the teenage mothers and their
children.

Introduction Green-blue spaces (GBS), such as parks, woodlands, and beaches, may be beneficial fo... more Introduction
Green-blue spaces (GBS), such as parks, woodlands, and
beaches, may be beneficial for population mental health and
wellbeing. However, there are few longitudinal studies on the
association between GBS and mental health and wellbeing,
and few that incorporate network analysis as opposed to simple
Euclidian proximity.
Objectives and Approach
We are examining the association between the availability of
GBS with wellbeing and common mental health disorders. We
will use geographic information systems (GIS) to create quarterly
household level GBS availability data using digital map
and satellite data (2008-2018) for over 1 million homes in
Wales, United Kingdom. We will link GBS availability to individual
level mental health (1.7 million people with General
Practitioner (GP) data) and data from the National Survey for
Wales (n = 24,000) on wellbeing (Warwick Edinburgh Mental
Wellbeing Scale (WEMWBS)) using the Secure Anonymised
Information Linkage (SAIL) databank.
Results
We created an historic dataset of GBS availability using road
network and path data to create quarterly household level GBS
exposures (2008-2018). We tested Residential Anonymised
Linking Fields (RALFs) and accurately linked 97% of individuals
and their health data to their home and GBS exposure.
The 1.65 million exposure-health data pairs, updated quarterly,
will enable a longitudinal panel study to be built. Using
GP recorded data on treatments, diagnoses, symptoms and
prescriptions for mental health problems we identified 35,000
people had a common mental health disorder in 2016, and
24,000 people answered the National Survey for Wales questions
about their wellbeing and use of GBS. We will explore
how house moves, and visits to GBS change the association
between GBS availability and outcomes.
Conclusion/Implications
This study fills the gap in the evidence base around environmental
planning policy to shape living environments to benefit
health. It will inform the planning and management of GBS in
urban and rural environments and contribute to international
work on impacts of the built environment on mental health
and wellbeing.