Local government spending and mental health: Untangling the impacts using a dynamic modelling approach.

This study investigated the impact of local government spending on mental health in England between 2013 and 2019. Guided by the "Health in All Policies" vision, which encourages the integration of health in all decision-making areas, we explored how healthcare and multiple nonmedical budgeting decisions related to population mental health. We used random curve general cross-lagged modelling to dynamically partition effects into the short-run (from t to t + 1) and long-run (from t to t + 2) impacts, account for unobserved area-level heterogeneity and reverse causality from health outcomes to financial investments, and comprehensive modelling of budget items as an interconnected system. Our findings revealed that spending in adult social care, healthcare, and law & order predicted long-term mental health gains (0.004-0.081 SDs increase for each additional 10% in expenditure). However, these sectors exhibited negative short-term impulses (0.012-0.077 SDs decrease for each additional 10% in expenditure), markedly offsetting the long-term gains. In turn, infrastructural and environmental spending related to short-run mental health gains (0.005-0.031 SDs increase for each additional 10% in expenditure), while the long-run effects were predominantly negative (0.005-0.028 SDs decrease for each additional 10% in expenditure). The frequent occurrence of short-run and long-run negative links suggested that government resources may not be effectively reaching the areas that are most in need. In the short-term, negative effects could also imply temporary disruptions to service delivery largely uncompensated by later mental health improvements. Nonetheless, some non-health spending policies, such as law & order and infrastructure, can be related to long-lasting positive mental health impacts.

Neighbourhood effects on educational attainment. What matters more: Exposure to poverty or exposure to affluence?

Neighbourhood effects studies typically investigate the negative effects on individual outcomes of living in areas with concentrated poverty. The literature rarely pays attention to the potential beneficial effects of living in areas with concentrated affluence. This poverty paradigm might hinder our understanding of spatial context effects. Our paper uses individual geocoded data from the Netherlands to compare the effects of exposure to neighbourhood affluence and poverty on educational attainment within the same statistical models. Using bespoke neighbourhoods, we create individual neighbourhood histories which allow us to distinguish exposure effects from early childhood and adolescence. We follow an entire cohort born in 1995 and we measure their educational level in 2018. The results show that, in the Netherlands, neighbourhood affluence has a stronger effect on educational attainment than neighbourhood poverty for all the time periods studied. Additionally, interactions with parental education indicate that children with higher educated parents are not affected by neighbourhood poverty. These results highlight the need for more studies on the effects of concentrated affluence and can inspire anti-segregation policies.

Pelizaeus-Merzbacher Disease: A Caregiver Assessment of Disease Impact.

Pelizaeus-Merzbacher disease is a rare X-linked leukodystrophy accompanied by central nervous system hypomyelination with a spectrum of clinical phenotypes. This is the first survey of caregivers of individuals with Pelizaeus-Merzbacher disease to investigate the presenting symptoms, path to diagnosis, identity and impact of most bothersome symptoms, and needs that future treatment should address. One hundred participants completed the survey. Results from this survey demonstrate that the majority of Pelizaeus-Merzbacher disease symptoms manifest before 2 years of age and commonly include deficits in gross and fine motor skills, speech, and communication. Caregivers rated difficulty crawling, standing, or walking as the most bothersome symptoms due to Pelizaeus-Merzbacher disease, with constipation and difficulty with sleep, manual dexterity, and speech and communication rated nearly as high. The most important treatment goals for caregivers were improved mobility and communication. The survey findings present a caregiver perspective of the impact of symptoms in Pelizaeus-Merzbacher disease and provide helpful guidance to affected families, physicians, and drug developers on the often-long path to diagnosis and the unmet medical needs of this patient population.

Continuing inequalities in COVID-19 mortality in England and Wales, and the changing importance of regional, over local, deprivation.

BACKGROUND: Observational studies have highlighted that where individuals live is far more important for risk of dying with COVID-19, than for dying of other causes. Deprivation is commonly proposed as explaining such differences. During the period of localised restrictions in late 2020, areas with higher restrictions tended to be more deprived. We explore how this impacted the relationship between deprivation and mortality and see whether local or regional deprivation matters more for inequalities in COVID-19 mortality. METHODS: We use publicly available population data on deaths due to COVID-19 and all-cause mortality between March 2020 and April 2021 to investigate the scale of spatial inequalities. We use a multiscale approach to simultaneously consider three spatial scales through which processes driving inequalities may act. We go on to explore whether deprivation explains such inequalities. RESULTS: Adjusting for population age structure and number of care homes, we find highest regional inequality in October 2020, with a COVID-19 mortality rate ratio of 5.86 (95% CI 3.31 to 19.00) for the median between-region comparison. We find spatial context is most important, and spatial inequalities higher, during periods of low mortality. Almost all unexplained spatial inequality in October 2020 is removed by adjusting for deprivation. During October 2020, one standard deviation increase in regional deprivation was associated with 20% higher local mortality (95% CI, 1.10 to 1.30). CONCLUSIONS: Spatial inequalities are greatest in periods of lowest overall mortality, implying that as mortality declines it does not do so equally. During the prolonged period of low restrictions and low mortality in summer 2020, spatial inequalities strongly increased. Contrary to previous months, we show that the strong spatial patterning during autumn 2020 is almost entirely explained by deprivation. As overall mortality declines, policymakers must be proactive in detecting areas where this is not happening, or risk worsening already strong health inequalities.

Multiscale Contextual Poverty in the Netherlands: Within and Between-Municipality Inequality.

Contextual poverty refers to high proportions of people with a low income in a certain (residential) space, and it can affect individual socioeconomic outcomes as well as decisions to move into or out of the neighbourhood. Contextual poverty is a multiscale phenomenon: Poverty levels at the regional scale reflect regional economic development, while meso-scale concentrations of poverty within cities are related to city-specific social, economic and housing characteristics. Within cities, poverty can also concentrate at micro spatial scales, which are often neglected, largely due to a lack of data. Exposure to poverty at lower spatial scales, such as housing blocks and streets, is important because it can influence individuals through social mechanisms such as role models or social networks. This paper is based on the premise that sociospatial context is necessarily multiscalar, and therefore contextual poverty is a multiscale problem which can be better understood through the inequality within and between places at different spatial scales. The question is how to compare different spatial contexts if we know that they include various spatial scales. Our measure of contextual poverty embraces 101 spatial scales and compares different locations within and between municipalities in the Netherlands. We found that the national inequality primarily came from the concentrations of poverty in areas of a few kilometres, located in cities, which have different spatial patterns of contextual poverty, such as multicentre, core-periphery and east-west. In addition to the inequality between municipalities, there are considerable within-municipality inequalities, particularly among micro-areas of a few hundred metres.

An adult presentation of a childhood disease.

ABSTRACT: Hand, foot, and mouth disease is a common childhood disease that can cause more severe symptoms and complications in infected adults, including myocarditis, meningitis, and encephalitis. This article describes the presentation and management of an adult with hand, foot, and mouth disease.

Interrogating structural inequalities in COVID-19 mortality in England and Wales.

BACKGROUND: Numerous observational studies have highlighted structural inequalities in COVID-19 mortality in the UK. Such studies often fail to consider the hierarchical, spatial nature of such inequalities in their analysis, leading to the potential for bias and an inability to reach conclusions about the most appropriate structural levels for policy intervention. METHODS: We use publicly available population data on COVID-19-related mortality and all-cause mortality between March and July 2020 in England and Wales to investigate the spatial scale of such inequalities. We propose a multiscale approach to simultaneously consider three spatial scales at which processes driving inequality may act and apportion inequality between these. RESULTS: Adjusting for population age structure and number of local care homes we find highest regional inequality in March and June/July. We find finer grained within region inequality increased steadily from March until July. The importance of spatial context increases over the study period. No analogous pattern is visible for non-COVID-19 mortality. Higher relative deprivation is associated with increased COVID-19 mortality at all stages of the pandemic but does not explain structural inequalities. CONCLUSIONS: Results support initial stochastic viral introduction in the South, with initially high inequality decreasing before the establishment of regional trends by June and July, prior to reported regionality of the 'second-wave'. We outline how this framework can help identify structural factors driving such processes, and offer suggestions for a long-term, locally targeted model of pandemic relief in tandem with regional support to buffer the social context of the area.

Opportunities, Enablers, and Barriers to the Use of Recorded Recovery Narratives in Clinical Settings.

Background: Recorded Recovery Narratives (RRNs) describing first-person lived experience accounts of recovery from mental health problems are becoming more available. Little is known about how RRNs can be used in clinical practice and clinical education. Aims: The aim of this paper is to enable implementation planning for RRN interventions by identifying determinants of uptake. The objective was to identify opportunities, barriers, and enablers to the uptake of RRN interventions in clinical practice and education. Method: Three phases of focus groups were conducted with multi-professional mental health clinicians. Phase 1 (4 groups, n = 25) investigated current and possible uses of RRNs, Phase 2 (2 groups, n = 15) investigated a specific intervention delivering recovery narratives. Phase 3 (2 groups, n = 12) investigated clinical education uses. Thematic analysis was conducted. Results: RRNs can reinforce the effectiveness of existing clinical practices, by reducing communication barriers and normalizing mental health problems. They can also extend clinical practice (increase hope and connection, help when stuck). Clinical considerations are the relationship with care pathways, choice of staff and stage of recovery. In educational use there were opportunities to access lived experience perspectives, train non-clinical staff and facilitate attitudinal change. Barriers and enablers related to design (ability to use online resources, accessibility of language, ability to individualize choice of narrative), risk (triggering content, staff skills to respond to negative effects), trust in online resource (evidence base, maintenance), and technology (cost of use, technology requirements). Conclusions: RRNs can both improve and extend existing clinical practice and be an important educational resource. RRNs can improve engagement and hope, and address internalized stigma. Beneficially incorporating RRNs into clinical practice and education may require new staff skills and improved technological resources in healthcare settings. Future work could focus on the use of peer support workers views on RRN use and how to avoid unnecessary and unhelpful distress. Trial Registration Number: Work in this paper has informed three clinical trials: ISRCTN11152837; ISRCTN63197153; ISRCTN76355273.

Changing occupational structures and residential segregation in New York, London and Tokyo.

Based on data from the 1980s, Sassen's influential book 'The Global City' interrogated how changes in the occupational structure affect socio-economic residential segregation in global cities. Here, using data for New York City, London and Tokyo, we reframe and answer this question for recent decades. Our analysis shows an increase in the share of high-income occupations, accompanied by a fall in low-income occupations in all three cities, providing strong evidence for a consistent trend of professionalization of the workforce. Segregation was highest in New York and lowest in Tokyo. In New York and London, individuals in high-income occupations are concentrating in the city centre, while low-income occupations are pushed to urban peripheries. Professionalization of the workforce is accompanied by reduced levels of segregation by income, and two ongoing megatrends in urban change: gentrification of inner-city neighbourhoods and suburbanization of poverty, with larger changes in the social geography than in levels of segregation.

Ageing and cohort trajectories in mental ill-health: An exploration using multilevel models.

Analyses of health over time must consider the potential impacts of ageing as well as any effects relating to cohort differences. The British Household Panel Survey (BHPS) and Understanding Society longitudinal studies are employed to assess trends in mental ill-health over a 26-year period. This analysis uses cross-classified multilevel models in an exploratory, non-parametric approach to evaluate age and cohort effects net of each other. Mental ill-health evidences an initial worsening trend as people age which then reverses and exhibits improvement in late-middle-age, before declining again in the latter stages of life. There were less defined cohort trends. The modelling technique also reveals the relative importance of the temporal contexts in relation to inter- and intra-individual effects on mental ill-health, demonstrating that the ageing and cohort dimensions explain little variation compared to these more dominant within and between influences. Ultimately, we suggest that researchers would benefit from wider use of this exploratory modelling strategy when evaluating underlying health trends and more research is now needed to explore potential explanations of these baseline trajectories.

The mechanisms and processes of connection: developing a causal chain model capturing impacts of receiving recorded mental health recovery narratives.

BACKGROUND: Mental health recovery narratives are a core component of recovery-oriented interventions such as peer support and anti-stigma campaigns. A substantial number of recorded recovery narratives are now publicly available online in different modalities and in published books. Whilst the benefits of telling one's story have been investigated, much less is known about how recorded narratives of differing modalities impact on recipients. A previous qualitative study identified connection to the narrator and/or to events in the narrative to be a core mechanism of change. The factors that influence how individuals connect with a recorded narrative are unknown. The aim of the current study was to characterise the immediate effects of receiving recovery narratives presented in a range of modalities (text, video and audio), by establishing the mechanisms of connection and the processes by which connection leads to outcomes. METHOD: A study involving 40 mental health service users in England was conducted. Participants were presented with up to 10 randomly-selected recovery narratives and were interviewed on the immediate impact of each narrative. Thematic analysis was used to identify the mechanisms of connection and how connection leads to outcome. RESULTS: Receiving a recovery narrative led participants to reflect upon their own experiences or those of others, which then led to connection through three mechanisms: comparing oneself with the narrative and narrator; learning about other's experiences; and experiencing empathy. These mechanisms led to outcomes through three processes: the identification of change (through attending to narrative structure); the interpretation of change (through attending to narrative content); and the internalisation of interpretations. CONCLUSIONS: This is the first study to identify mechanisms and processes of connection with recorded recovery narratives. The empirically-based causal chain model developed in this study describes the immediate effects on recipients. This model can inform selection of narratives for use in interventions, and be used to support peer support workers in recounting their own recovery narratives in ways which are maximally beneficial to others.

Conceptual framework for personal recovery in mental health among children and adolescents: a systematic review and narrative synthesis protocol.

INTRODUCTION: Personal recovery has been defined as 'a profound personal and unique process for the individual to change their attitudes, values, feelings, goals, abilities and roles in order to achieve a satisfactory, hopeful and productive way of life, with the possible limitations of the illness'. However, research on personal recovery has focused almost exclusively on adults. This project aims to systematically review the available literature on definitions of personal recovery among children and adolescents with mental health conditions and to undertake a narrative synthesis to develop a conceptual framework of recovery. METHODS AND ANALYSIS: Systematic review and narrative synthesis consisting (1) searching scientific literature databases, (2) handsearching, (3) citation tracking, (4) grey literature searching, (5) web-based searching and expert consultation. We will include qualitative and quantitative studies or systematic reviews providing a definition, theoretical or conceptual framework, domains or dimensions of personal recovery among eligible participants. The study will follow standard systematic review methodology for study selection and data extraction. We will assess quality of the evidence using tools appropriate for each study design. We will develop a new conceptual framework using a modified narrative synthesis approach, as follows: (1) describing eligible studies and conducting a preliminary synthesis, (2) determining relationships within and between studies and (3) determining the robustness of the synthesis. ETHICS AND DISSEMINATION: We obtained a waiver of approval from our local Research Ethics Committee. Results will be disseminated via publications in international peer-reviewed journals and conference proceedings.This study will result in a theoretical framework that is based on an exhaustive review of the literature and the input of experts in the field of recovery. We expect that this framework will foster a better understanding of the stages and processes of recovery in children and adolescents with mental health conditions. PROSPERO REGISTRATION NUMBER: CRD42018064087.

Genetic and Environmental Risk Factors Associated With Trajectories of Depression Symptoms From Adolescence to Young Adulthood.

Importance: Less favorable trajectories of depressive mood from adolescence to early adulthood are associated with current and later psychopathology, impaired educational attainment, and social dysfunction, yet the genetic and environmental risk factors associated with these trajectories are not fully established. Examining what risk factors are associated with different trajectories of depressive mood could help identify the nature of depression symptoms and improve preventive interventions for those at most risk. Objective: To examine the differential associations of genetic and environmental risk factors with trajectories of depression symptoms among individuals observed from ages 10 to 24 years. Design, Setting, and Participants: In a longitudinal cohort study established in 1990 and currently ongoing (the Avon Longitudinal Study of Parents and Children [ALSPAC]), growth mixture modeling was used to identify trajectories of depression symptoms in 9394 individuals in the United Kingdom. Associations of different risk factors with these trajectories were then examined. Analysis was conducted between August 2018 and January 2019. Main Outcomes and Measures: Trajectories were composed from depression symptoms measured using the Short Mood and Feelings Questionnaire at 9 occasions from ages 10 to 24 years. Risk factors included sex, a polygenic risk score taken from a recent genome-wide association study of depression symptoms, maternal postnatal depression, partner cruelty to the offspring's mother when the child was aged 2 to 4 years, childhood anxiety at age 8 years, and being bullied at age 10 years. Results: Data on all risk factors, confounders, and the outcome were available for 3525 individuals, including 1771 (50.2%) who were female. Trajectories were assessed between the mean (SD) age of 10.7 (0.3) years and mean (SD) age of 23.8 (0.5) years. Overall, 5 distinct trajectories of depression symptoms were identified: (1) stable low (2506 individuals [71.1%]), (2) adolescent limited (325 individuals [9.2%]), (3) childhood limited (203 individuals [5.8%]), (4) early-adult onset (393 individuals [11.1%]), and (5) childhood persistent (98 individuals [2.8%]). Of all the associations of risk factors with trajectories, sex (odds ratio [OR], 6.45; 95% CI, 2.89-14.38), the polygenic risk score for depression symptoms (OR, 1.47; 95% CI, 1.10-1.96), and childhood anxiety (OR, 1.30; 95% CI, 1.16-1.45) showed the strongest association with the childhood-persistent trajectory of depression symptoms compared with the stable-low trajectory. Maternal postnatal depression (OR, 2.39; 95% CI, 1.41-4.07) had the strongest association with the early-adult-onset trajectory, while partner cruelty to mother (OR, 2.30; 95% CI, 1.36-3.90) had the strongest association with the adolescent-limited trajectory. Bullying (OR, 8.08; 95% CI, 4.92-13.26) showed the strongest association with the childhood-limited trajectory. Conclusions and Relevance: The least favorable trajectories of depression symptoms (childhood persistent and early-adult onset) were associated with both genetic and environmental risk factors, but the 2 trajectories of limited duration that had resolved by early adulthood (childhood limited and adolescent limited) were not associated with the polygenic risk score or maternal postnatal depression. Bullying was strongly associated with both the childhood-persistent and childhood-limited trajectories, suggesting that this risk factor may have a time-specific effect. These findings suggest that examining genetic and multiple time-specific environmental antecedents could help identify trajectories of varying onset and chronicity.

Using sibling data to explore the impact of neighbourhood histories and childhood family context on income from work.

Previous research has reported evidence of intergenerational transmissions of neighbourhood status and social and economic outcomes later in life. Research also shows neighbourhood effects on adult incomes of both childhood and adult neighbourhood experiences. However, these estimates of neighbourhood effects may be biased because confounding factors originating from the childhood family context. It is likely that part of the neighbourhood effects observed for adults, are actually lingering effects of the family in which someone grew up. This study uses a sibling design to disentangle family and neighbourhood effects on income, with contextual sibling pairs used as a control group. The sibling design helps us to separate the effects of childhood family and neighbourhood context from adult neighbourhood experiences. Using data from Swedish population registers, including the full Swedish population, we show that the neighbourhood effect on income from both childhood and adult neighbourhood experiences, is biased upwards by the influence of the childhood family context. Ultimately, we conclude that there is a neighbourhood effect on income from adult neighbourhood experiences, but that the childhood neighbourhood effect is actually a childhood family context effect. We find that there is a long lasting effect of the family context on income later in life, and that this effect is strong regardless the individual neighbourhood pathway later in life.

Characteristics of mental health recovery narratives: Systematic review and narrative synthesis.

BACKGROUND: Narratives of recovery from mental health distress have played a central role in the establishment of the recovery paradigm within mental health policy and practice. As use of recovery narratives increases within services, it is critical to understand how they have been characterised, and what may be missing from their characterisation thus far. The aim of this review was to synthesise published typologies in order to develop a conceptual framework characterising mental health recovery narratives. METHOD: A systematic review was conducted of published literature on the characteristics of mental health recovery narratives. Narrative synthesis involved identifying characteristics and organising them into dimensions and types; and subgroup analysis based on study quality, narrator involvement in analysis, diagnosis of psychosis and experience of trauma. The synthesis was informed by consultation with a Lived Experience Advisory Panel and an academic panel. The review protocol was pre-registered (Prospero CRD42018090188). RESULTS: 8951 titles, 366 abstracts and 121 full-text articles published January 2000-July 2018 were screened, of which 45 studies analysing 629 recovery narratives were included. A conceptual framework of mental health recovery narratives was developed, comprising nine dimensions (Genre; Positioning; Emotional Tone; Relationship with Recovery; Trajectory; Use of Turning Points; Narrative Sequence; Protagonists; and Use of Metaphors), each containing between two and six types. Subgroup analysis indicated all dimensions were present across most subgroups, with Turning Points particularly evident in trauma-related studies. CONCLUSIONS: Recovery narratives are diverse and multidimensional. They may be non-linear and reject coherence. To a greater extent than illness narratives, they incorporate social, political and rights aspects. Approaches to supporting development of recovery narratives should expand rather than reduce available choices. Research into the narratives of more diverse populations is needed. The review supports trauma-informed approaches, and highlights the need to understand and support post-traumatic growth for people experiencing mental health issues.

Identifying Critical Points of Trajectories of Depressive Symptoms from Childhood to Young Adulthood.

Depression is a common mental illness and research has focused on late childhood and adolescence in an attempt to prevent or reduce later psychopathology and/or social impairments. It is important to establish and study population-averaged trajectories of depressive symptoms across adolescence as this could characterise specific changes in populations and help identify critical points to intervene with treatment. Multilevel growth-curve models were used to explore adolescent trajectories of depressive symptoms in 9301 individuals (57% female) from the Avon Longitudinal Study of Parents and Children, a UK based pregnancy cohort. Trajectories of depressive symptoms were constructed for males and females using the short mood and feelings questionnaire over 8 occasions, between 10 and 22 years old. Critical points of development such as age of peak velocity for depressive symptoms (the age at which depressive symptoms increase most rapidly) and the age of maximum depressive symptoms were also derived. The results suggested that from similar initial levels of depressive symptoms at age 11, females on average experienced steeper increases in depressive symptoms than males over their teenage and adolescent years until around the age of 20 when levels of depressive symptoms plateaued and started to decrease for both sexes. Females on average also had an earlier age of peak velocity of depressive symptoms that occurred at 13.5 years, compared to males who on average had an age of peak velocity at 16 years old. Evidence was less clear for a difference between the ages of maximum depressive symptoms which were on average 19.6 years for females and 20.4 for males. Identifying critical periods for different population subgroups may provide useful knowledge for treating and preventing depression and could be tailored to be time specific for certain groups. Possible explanations and recommendations are discussed.

Occupied with classification: Which occupational classification scheme better predicts health outcomes?

Health inequalities continue to grow despite continuous policy intervention. Work, one domain of health inequalities, is often included as a component of social class rather than as a determinant in its own right. Many social class classifications are derived from occupation types, but there are other components within them that mean they may not be useful as proxies for occupation. This paper develops the exposome, a life-course exposure model developed by Wild (2005), into the worksome, allowing for the explicit consideration of both physical and psychosocial exposures and effects derived from work and working conditions. The interactions between and within temporal and geographical scales are strongly emphasised, and the interwoven nature of both psychosocial and physical exposures is highlighted. Individuals within an occupational type can be both affected by and effect upon occupation level characteristics and health measures. By using the worksome, occupation types are separated from value-laden social classifications. This paper will empirically examine whether occupation better predicts health measures from the European Working Conditions Survey (EWCS). Logistic regression models using Bayesian MCMC estimation were run for each classification system, for each health measure. Health measures included, for example, whether the respondent felt their work affected their health, their self-rated health, pain in upper or lower limbs, and headaches. Using the Deviance Information Criterion (DIC), a measure of predictive accuracy penalised for model complexity, the models were assessed against one another. The DIC shows empirically which classification system is most suitable for use in modelling. The 2-digit International Standard Classification of Occupations showed the best predictive accuracy for all measures. Therefore, examining the relationship between health and work should be done with classifications specific to occupation or industry rather than socio-economic class classifications. This justifies the worksome, allowing for a conceptual framework to link many forms of work-health research.

Residential mobility: Towards progress in mobility health research.

Research into health disparities has long recognized the importance of residential mobility as a crucial factor in determining health outcomes. However, a lack of connectivity between the health and mobility literatures has led to a stagnation of theory and application on the health side, which lacks the detail and temporal perspectives now seen as critical to understanding residential mobility decisions. Through a critical re-think of mobility processes with respect to health outcomes and an exploitation of longitudinal analytical techniques, we argue that health geographers have the potential to better understand and identify the relationship that residential mobility has with health.

Confounding and collinearity in regression analysis: a cautionary tale and an alternative procedure, illustrated by studies of British voting behaviour.

Many ecological- and individual-level analyses of voting behaviour use multiple regressions with a considerable number of independent variables but few discussions of their results pay any attention to the potential impact of inter-relationships among those independent variables-do they confound the regression parameters and hence their interpretation? Three empirical examples are deployed to address that question, with results which suggest considerable problems. Inter-relationships between variables, even if not approaching high collinearity, can have a substantial impact on regression model results and how they are interpreted in the light of prior expectations. Confounded relationships could be the norm and interpretations open to doubt, unless considerable care is applied in the analyses and an extended principal components method for doing that is introduced and exemplified.

Stressed out? An investigation of whether allostatic load mediates associations between neighbourhood deprivation and health.

Deprived neighbourhoods have long been associated with poorer health outcomes. However, many quantitative studies have not evidenced the mechanisms through which place 'gets under the skin' to influence health. The increasing prevalence of biosocial data provides new opportunities to explore these mechanisms and incorporate them into models of contextual effects. The stress pathway is a key biosocial mechanism; however, few studies have explicitly tested it in neighbourhood associations. This paper addresses this gap by investigating whether allostatic load, a biological response to chronic stress, mediates relationships of neighbourhood deprivation to physical and mental health. Data from UK Understanding Society is used to undertaken a multilevel mediation analysis. Allostatic load is found to mediate the association between neighbourhood deprivation and health, substantiating the biological mechanism of the stress pathway. More deprived areas are associated with higher allostatic load, and in turn worse allostatic load relates to poorer physical and mental health. Allostatic load is a stronger mediator of physical health than mental health, suggesting the stress pathway is more pertinent to explaining physical health gradients. Heterogeneity in the results between physical and mental health suggests more research is needed to disentangle the biosocial processes that could be important to health and place relationships.