The journey of service users with complex mental health needs: a qualitative study.

Background: This study aimed to provide a robust picture of the journey of service users with complex mental health needs by evaluating the perspectives of service users and carers with lived experience of services and gaining clinician views about decision making in relation to this cohort. Methods: A qualitative design was used. Service users (n = 11), carers (n = 10) and clinicians (n = 18) took part in semi-structured interviews, which were transcribed verbatim and analysed using thematic analysis. Results: The following themes were identified by participants: 'relationships with staff,' 'treatment options, pathways and availability,' 'the role of autonomy in recovery,' 'impact of out-of-area placements,' and 'specialist training for staff.' The findings demonstrated that the journey of serviceusers can be impacted by a wide range of factors, including relationships with staff, the nature of support offered, community response, financial constraints, and organisational goals around bed pressures. Conclusions: Recommendations include the need for staff to work in partnership with service users and carers, foster autonomy, access specialised suicide prevention training, and agree discharge and contingency plans with service users. Further work is needed to deliver the best possible experience for individuals with complex mental health needs and those who care for them.

Ethnic density and first episode psychosis in the British Pakistani population: findings from the East Lancashire Early Intervention Service.

BACKGROUND: Elevated risk of psychosis for ethnic minority groups has generally been shown to be mitigated by high ethnic density. However, past survey studies examining UK Pakistani populations have shown an absence of protective ethnic density effects, which is not observed in other South Asian groups. AIMS: To assess the ethnic density effect at a local neighbourhood level, in the UK Pakistani population in East Lancashire. METHOD: Data was collected by the East Lancashire Early Intervention Service, identifying all cases of first episode psychosis (FEP) within their catchment area between 2012 and 2020. Multilevel Poisson regression analyses were used to compare incidence rates between Pakistani and White majority groups, while controlling for age, gender and area-level deprivation. The ethnic density effect was also examined by comparing incidence rates across high and low density areas. RESULTS: A total of 455 cases of FEP (364 White, 91 Pakistani) were identified. The Pakistani group had a higher incidence of FEP compared to the White majority population. A clear effect of ethnic density on rates of FEP was shown, with those in low density areas having higher incidence rates compared to the White majority, whereas incidence rates in high density areas did not significantly differ. Within the Pakistani group, a dose-response effect was also observed, with risk of FEP increasing incrementally as ethnic density decreased. CONCLUSIONS: Higher ethnic density related to lower risk of FEP within the Pakistani population in East Lancashire, highlighting the impact of local social context on psychosis incidence.

"No Abnormality Detected": A Mixed-Methods Examination of Emergency Department Coding Practices for People in Suicidal Crisis.

BACKGROUND: Accurate identification of suicidal crisis presentations to emergency departments (EDs) can lead to timely mental health support, improve patient experience, and support evaluations of suicide prevention initiatives. Poor coding practices within EDs are preventing appropriate patient care. Aims of the study are (1) examine the current suicide-related coding practices, (2) identify the factors that contribute to staff decision-making and patients receiving the incorrect code or no code. METHOD: A mixed-methods study was conducted. Quantitative data were collated from six EDs across Merseyside and Cheshire, United Kingdom from 2019 to 2021. Attendances were analyzed if they had a presenting complaint, chief complaint, or primary diagnosis code related to suicidal crisis, suicidal ideation, self-harm or suicide attempt. Semi-structured interviews were conducted with staff holding various ED positions (n = 23). RESULTS: A total of 15,411 suicidal crisis and self-harm presentations were analyzed. Of these, 21.8% were coded as 'depressive disorder' and 3.8% as 'anxiety disorder'. Absence of an appropriate suicidal crisis code resulted in staff coding presentations as 'no abnormality detected' (23.6%) or leaving the code blank (18.4%). The use of other physical injury codes such as 'wound forearm', 'head injury' were common. Qualitative analyses elucidated potential causes of inappropriate coding, such as resource constraints and problems with the recording process. CONCLUSION: People attending EDs in suicidal crisis were not given a code that represented the chief presentation. Improved ED coding practices related to suicidal crisis could result in considerable benefits for patients and more effective targeting of resources and interventions.

Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review.

BACKGROUND: Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group. METHODS: MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies. RESULTS: Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs. CONCLUSION: Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention.

Perspectives of service users and carers with lived experience of a diagnosis of personality disorder: A qualitative study.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Personality disorder is a serious mental health condition affecting up to 52% of psychiatric outpatients and 70% of inpatients and forensic patients. People with a diagnosis of personality disorder have higher morbidity and mortality than those without. Service users and carers reported a lack of training for staff in the management of individuals with a diagnosis of personality disorder, particularly with regard to self-harm and suicidal behaviours. Staff burnout creates barriers to compassionate person-centred care for individuals with a diagnosis of personality disorder as staff struggled to accommodate the nature of the presentation when under significant emotional, psychological and professional strain caused by understaffing and lack of support. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper adds new knowledge by informing services of ways to improve care provision from the perspectives of both carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with a diagnosis of a personality disorder should be adopted, and personality disorder training introduced for all healthcare practitioners, to improve patient outcomes. ABSTRACT: INTRODUCTION: There is limited understanding of the experience of people with complex mental health (CMH) needs, including those with a diagnosis of personality disorder (PD) and carers of those individuals. Little is known about carers of those in inpatient forensic settings, yet it has been identified that they may have additional needs when compared to general carers. Research highlights that community carer support services were perceived as inadequate and out-of-area placements were described as putting an added strain on ability to support loved ones. Understanding PD within a population of people with CMH needs and how a diagnosis described as PD impacts on care and treatment experience is vital to providing high-quality care. AIM: To evaluate the care experience of service users and carers with lived experience of a diagnosis of PD and out-of-area placements. METHOD: Semi-structured interviews were conducted with six service users and four carers to explore the experiences and perspectives of people with a diagnosis of PD. Interviews were audio recorded and thematically analysed. RESULTS: Four interrelated themes were developed; Influence of a diagnosis of PD on Staff, Early and Appropriate Intervention, Recognition of the Individual and Training and Knowledge of people with a diagnosis of PD. DISCUSSION: Anti-stigma interventions for staff, research on care provision and structural changes to services including more evidence-based therapy for individuals with a diagnosis of PD may help reduce disparate treatment and improve prognosis for recovery. IMPLICATIONS FOR PRACTICE: This paper informs services of ways to improve care provision from the perspective of carers and service users. A more holistic and less medicalised approach to the treatment of problems associated with diagnoses of PD should be adopted, and PD training for all healthcare practitioners to improve patient outcomes.

Socioeconomic Predictors of Crisis and Clinical Pathways Among People Contacting a Mental Health Crisis Line.

Objective: Crisis lines are the first mental health service contact point for many people, making them a vital community and public health intervention. Given the current and potential utility of crisis lines, better understanding the characteristics, socioeconomic factors and subsequent referral pathways of callers is critical to identifying targeted ways to improve such services. Study Design: The dataset captured calls to the Cheshire & Wirral Partnership NHS Foundation Trust (CWP) crisis line between August 2020 and August 2021. Calls were examined if self-harm, risk to self, or overdose were reported by the caller. Descriptive analyses were conducted to produce a clinical and demographic profile of the callers using the crisis line. Results: Call handlers were significantly more likely to call 999, hand over to a practitioner and less likely to provide advice and guidance if self-harm, risk to self or overdose was reported. Social issues were found to be significantly associated with all 3 outcomes: self-harm, risk to self and overdose. Conclusion: The current study provides the first exploratory analysis of the socioeconomic factors and resultant care pathways for those contacting a UK crisis line service. The findings have important implications for community early intervention efforts to reduce self-harm and suicidal behaviours.

Staff perspectives of emergency department pathways for people attending in suicidal crisis: A qualitative study.

WHAT IS KNOWN ON THE SUBJECT?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED. Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow-up care provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received. Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis. ABSTRACT: INTRODUCTION: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway. AIMS: To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis. METHOD: Qualitative study guided by thematic analysis of semi-structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England. RESULTS: Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. DISCUSSION: Staff felt unequipped to deal with suicide-related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction. IMPLICATIONS FOR PRACTICE: Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED.

Predictors of self-harm and emergency department attendance for self-harm in deprived communities.

Emergency departments (EDs) are often the first point of contact for individuals following self-harm. The majority of previous research relies on hospital-based data, yet only a minority of individuals who self-harm in the community present to healthcare services. The study design is cross-sectional survey design. Data from the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC) Household Health Survey, a community-based public health survey in North West England, was collected using stratified random sampling. Three thousand four hundred twelve people were recruited in 2018 from relatively disadvantaged areas. The sample included 1490 men and 1922 women aged 18 to 100 years (M = 49.37, SD = 18.91). Logistic regression analysis was employed to examine demographic, health and socioeconomic predictors of self-harm and ED attendance for self-harm. Age (18-24 years), lower financial status, depression, anxiety and physical and mental health co-morbidity was associated with significantly higher levels of self-harm. People aged 18-24 years, with physical and mental health co-morbidity and lower levels of social support had significantly higher levels of attending EDs for self-harm. Improving people's financial situations, social connectivity, mental and physical health may help to reduce individual risk for self-harm and strain on health services.

Symptoms of Paranoia Experienced by Students of Pakistani Heritage in England: The Role of Explicit and Implicit Identities and Perceived Discrimination.

ABSTRACT: Individuals belonging to ethnic minority groups are less likely to experience symptoms of psychosis, such as paranoia, if they live in areas with high proportions of people from the same ethnic background. This effect may be due to processes associated with group belonging (social identification). We examined whether the relationship between perceived discrimination and paranoia was moderated by explicit and implicit Pakistani/English identification among students of Pakistani heritage (N = 119). Participants completed measures of explicit and implicit Pakistani and English identity, a measure of perceived discrimination, and a measure of paranoia. Perceived discrimination was the strongest predictor of paranoia (0.31). Implicit identities moderated the relationship between perceived discrimination and paranoia (-0.17). The findings suggest that higher levels of implicit Pakistani identity were most protective against high levels of paranoia (0.26, with low implicit English identity; 0.78, with medium English identity; 1.46, with high English identity). Overall, a complex relationship between identity and paranoia was apparent.

The psychophysiological mechanisms of real-world time experience.

Our sense of time is fallible, often resulting in the sensation of time flying by quickly or dragging slowly. It has been suggested that changes in sympathetic (SNS) and parasympathetic nervous system (PNS) activity may influence the perceived passage of time, however this proposition has never been tested during real-world temporal experience. The current study directly tested the relationship between the passage of time and SNS-PNS activity in the real-world. Sixty-seven participants completed a normal day's activities whilst wearing sensors to capture electrocardiography (ECG), electrodermal activity (EDA) and movement. They also provided hourly rating of the subjective speed at which time was passing. Results revealed that greater SNS activity (e.g., increased heart rate, frequency of phasic skin conductance response) was associated with time passing more quickly. PNS activity was not related to time experience. Whilst the findings support previous suggestions that changes in physiological arousal are associated with distortions to the passage of time, the effects are small and other factors are likely to contribute to real-world temporal experience.

COMplex mental health PAThways (COMPAT) Study: A mixed methods study to inform an evidence-based service delivery model for people with complex needs: Study protocol.

BACKGROUND: Mental health services for adults, as they are currently configured, have been designed to provide predominantly community-based interventions. It has long been recognised that some patients have such significant clinical and/or risk needs that those needs cannot be adequately met within standard service delivery models, resulting in a pressing need to consider the best models for this group of people. This paper shares a protocol for a mixed methods study that aims to understand: the profile and history of service users described as having complex needs; the decision-making processes by clinicians that lead to complex needs categorisation; service users and carers experience of service use; and, associated economic impact. This protocol describes a comprehensive evaluation that aims to inform an evidence-based service delivery model for people with complex needs. METHODS: We will use a mixed methods design, combining quantitative and qualitative methods using in-depth descriptive and inferential analysis of patient records, written medical notes and in-depth interviews with service users, carers, and clinicians. The study will include five components: (1) a quantitative description and analysis of the demographic clinical characteristics of the patient group; (2) an economic evaluation of alternative patient pathways; (3) semi-structured interviews about service user and carer experiences; (4) using data from components 1-3 to co-produce vignettes jointly with relevant stakeholders involved in the care of service users with complex mental health needs; and, (5) semi-structured interviews about clinical decision-making by clinicians in relation to this patient group, using the vignettes as example case studies. DISCUSSION: The study's key outcomes will be to: examine the resource use and cost-impact associated with alternative care pathways to the NHS and other sectors of the economy (including social care); explore patient health and non-health outcomes associated with alternative care pathways; and, gain an understanding of a complex service user group and how treatment decisions are made to inform consistent and person-centred future service delivery.

The empirical evidence base for the use of the HCR-20: A narrative review of study designs and transferability of results to clinical practice.

The HCR-20, a widely used method of assessing and managing risk, relies on the structured professional judgement approach. This paper reports a narrative literature review of the HCR-20 studies to explore the applicability of the study results to the use of the HCR-20 in clinical practice. From a literature search using terms "HCR-20" and "HCR 20", 206 papers were included. Of studies using the HCR-20 version 2 (n = 191), 92% (n = 176) relied on variables based on scores derived by adding item scores, and 50% (n = 95) tested the HCR-20 using predictive validity methodology. Of the HCR-20 version 3 studies (n = 21), the "presence of risk factors" step was the most commonly examined (n = 18, 86%), but 2 of the 7 steps ("scenario planning" and "management") were not examined at all. Amongst those studies whose primary focus was on the HCR-20, 67% (n = 64/95) did so by assessing the predictive validity of the tool. Only one employed a design to test whether the use of the HCR-20 affected violence rates. The predominant study design provides support for the use of the HCR-20 as an actuarial tool, and there is limited empirical evidence in support of its effectiveness as a structured professional judgement approach to the assessment and management of the risk of violence.

Does neighbourhood identification buffer against the effects of socioeconomic disadvantage on self-harm?

BACKGROUND: Socioeconomic disadvantage and lack of group belonging (i.e., social identity) have been linked to poor mental health. However, no research has investigated the relationship between neighbourhood identity and self-harm, nor whether identifying with one's neighbourhood can mitigate the effects of economic stress on self-harm. METHODS: Pre-registered secondary data analysis of a large (N = 3412) community health survey conducted in disadvantaged areas of North West England. RESULTS: Despite the sample having a relatively high and therefore restricted level of disadvantage, individual and geographic indicators of disadvantage, as well as neighbourhood identification, were unique and strong predictors of self-harm thoughts and behaviours across several analyses. Specifically, experiencing disadvantage and disidentification predicted significantly higher odds of self-harm and self-harm thoughts. No consistent interactive effects emerged. LIMITATIONS: The cross-sectional design limits firm conclusions regarding causal effects of neighbourhood identity and disadvantage on self-harm. However, causal direction is supported by past research and theory. The data is self-report, which is subject to response bias. The sample was also recruited from a region of the UK with low numbers of residents from ethnic minority backgrounds. CONCLUSIONS: The results are consistent with past research indicating an association between social identity and better mental health, but for the first time extend these effects to self-harm. The findings demonstrate the importance of considering social and economic factors when attempting to prevent suicide and understand and treat self-harm thoughts.

Investigation to identify individual socioeconomic and health determinants of suicidal ideation using responses to a cross-sectional, community-based public health survey.

OBJECTIVES: To address a gap in knowledge by simultaneously assessing a broad spectrum of individual socioeconomic and potential health determinants of suicidal ideation (SI) using validated measures in a large UK representative community sample. DESIGN: In this cross-sectional design, participants were recruited via random area probability sampling to participate in a comprehensive public health survey. The questionnaire examined demographic, health and socioeconomic factors. Logistic regression analysis was employed to identify predictors of SI. SETTING: Community setting from high (n=20) and low (n=8) deprivation neighbourhoods across the North West of England, UK. PARTICIPANTS: 4319 people were recruited between August 2015 and January 2016. There were 809 participants from low-deprivation neighbourhoods and 3510 from high-deprivation neighbourhoods. The sample comprised 1854 (43%) men and 2465 (57%) women. PRIMARY OUTCOME MEASURES: SI was the dependent variable which was assessed using item 9 of the Patient Health Questionnaire-9 instrument. RESULTS: 454 (11%) participants reported having SI within the last 2 weeks. Model 1 (excluding mental health variables) identified younger age, black and minority ethnic (BME) background, lower housing quality and current smoker status as key predictors of SI. Higher self-esteem, empathy and neighbourhood belonging, alcohol abstinence and having arthritis were protective against SI. Model 2 (including mental health variables) found depression and having cancer as key health predictors for SI, while identifying as lesbian, gay, bisexual, transgender or queer (LGBTQ) and BME were significant demographic predictors. Alcohol abstinence, having arthritis and higher empathy levels were protective against SI. CONCLUSIONS: This study suggests that it could be useful to increase community support and sense of belonging using a public health approach for vulnerable groups (e.g. those with cancer) and peer support for people who identify as LGBTQ and/or BME. Also, interventions aimed at increasing empathic functioning may prove effective for reducing SI.

The relationship between ingroup identity and Paranoid ideation among people from African and African Caribbean backgrounds.

OBJECTIVES: People from ethnic minority groups experience higher rates of paranoid delusions compared with people from ethnic majority groups. Identifying with social groups has been shown to protect against mental health symptoms; however, no studies have investigated the relationship between social identification and paranoia in ethnic minority populations. Here, we investigated the association between British identification and paranoia in a sample of people from African and African Caribbean backgrounds living in the United Kingdom. We also assessed the role of potential mediating (self-esteem and locus of control) and moderating (contact with White British people) factors. DESIGN: Cross-sectional quantitative survey design. METHODS: We recruited 335 people from African and African Caribbean backgrounds who completed online self-report measures of identification with Great Britain, self-esteem, locus of control, positive and negative contact with White British people, and paranoia. RESULTS: A parallel moderated mediation model indicated that British identification was associated with lower paranoia when participants experienced primarily positive contact with White British people. British identification was associated with higher paranoia when participants had primarily negative contact with White British people. Both effects were mediated by changes in locus of control, but self-esteem was not implicated in either pathway. CONCLUSIONS: Identification with the majority culture is associated both positively and negatively with paranoid beliefs depending on the types of social interactions people experience. The findings have implications for preventative social prescribing initiatives and for understanding the causes of the high rates of psychosis in ethnic minority populations. PRACTITIONER POINTS: People from African and African Caribbean backgrounds experience high rates of paranoia, which may stem from social causes such as lack of belonging and negative social experiences. Among people from African backgrounds living in the UK, British identification is associated with lower paranoia when people's social experiences with White British people are positive and higher paranoia when their social experiences with White British people are negative. It is recommended that social interventions designed to reduce paranoia in vulnerable groups foster positive social contact and community belonging, which should enhance feelings of personal control. Understanding the complex interplay between social identity and social contact in the development of paranoia may help therapists and researchers better understand the phenomenology and risk factors of paranoid symptomology.

The longitudinal NIHR ARC North West Coast Household Health Survey: exploring health inequalities in disadvantaged communities.

BACKGROUND: The Household Health Survey (HHS) was developed to understand the socioeconomic determinants of mental and physical health, and health inequalities in health and social care. This paper aims to provide a detailed rationale of the development and implementation of the survey and explore socio-economic variations in physical and mental health and health care. METHODS: This comprehensive longitudinal public health survey was designed and piloted in a disadvantaged area of England, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. After piloting, the HHS was implemented across 28 neighbourhoods - 10 disadvantaged neighbourhoods for learning (NfLs), 10 disadvantaged comparator sites, and eight relatively advantaged areas, in 2015 and 2018. Participants were recruited via random sampling of households in pre-selected neighbourhoods based on their areas of deprivation. RESULTS: 7731 residents participated in Wave 1 (N = 4319) and 2 (n = 3412) of the survey, with 871 residents having participated in both. Mental health, physical health, employment, and housing quality were poorer in disadvantaged neighbourhoods than in relatively advantaged areas. CONCLUSIONS: This survey provides important insights into socio-economic variations in physical and mental health, with findings having implications for improved care provision to enable residents from any geographical or socio-economic background to access suitable care.

Predictors of emergency department and GP use among patients with mental health conditions: a public health survey.

BACKGROUND: High demand for health services is an issue of current importance in England, in part because of the rapidly increasing use of emergency departments (EDs) and GP practices for mental health conditions and the high cost of these services. AIM: To examine the social determinants of health service use in people with mental health issues. DESIGN AND SETTING: Twenty-eight neighbourhoods, each with a population of 5000-10 000 people, in the north west coast of England with differing levels of deprivation. METHOD: A comprehensive public health survey was conducted, comprising questions on housing, physical health, mental health, lifestyle, social issues, environment, work, and finances. Poisson regression models assessed the effect of mental health comorbidity, mental and physical health comorbidity, and individual mental health symptoms on ED and general practice attendances, adjusting for relevant socioeconomic and lifestyle factors. RESULTS: Participants who had both a physical and mental health condition reported attending the ED (rate ratio [RR] = 4.63, 95% confidence interval [CI] = 2.86 to 7.51) and general practice (RR = 3.82, 95% CI = 3.16 to 4.62) more frequently than all other groups. Having a higher number of mental health condition symptoms was associated with higher general practice and ED service use. Depression was the only mental health condition symptom that was significantly associated with ED attendance (RR = 1.41, 95% CI = 1.05 to 1.90), and anxiety was the only symptom significantly associated with GP attendance (RR = 1.19, 95% CI = 1.03 to 1.38). CONCLUSION: Mental health comorbidities increase the risk of attendances to both EDs and general practice. Further research into the social attributes that contribute to reduced ED and general practice attendance rates is needed.

Public involvement in the dissemination of the North West Coast Household Health Survey: Experiences and lessons of co-producing research together.

BACKGROUND: Engaging with the public is a key element of health research; however, little work has examined experiences of public involvement in research dissemination. The aim of this paper was to assess the extent of public involvement, experiences of public advisers and resulting changes in the dissemination of the North West Coast Household Health Survey (HHS). METHODS: Three writing groups allowed public advisers to contribute to the dissemination of the HHS. A public workshop was set up to aid the co-production of the research evidence and discuss the experiences of public advisers involved with the survey in March 2018. A focus group with public advisers was conducted in August 2018 to understand their experiences of involvement. Data were analysed using thematic analysis and coded by two researchers. Writing groups are still on-going. RESULTS: Fourteen public advisers contributed via three face-to-face writing groups, by actively interpreting findings and helping in the write-up of research articles and by presenting talks at the public workshop. At the workshop, seven public advisors contributed to setting priorities for data analysis from the HHS. Five public advisers took part in the focus group, which highlighted that whilst public advisers were generally satisfied with their involvement, they would like to be involved in more activities. CONCLUSIONS: Members of the public shaped the dissemination of evidence and provided guidance for future steps. Public advisers were mostly positive about their involvement in the dissemination of the HHS, but highlighted the need for more transparency and support from researchers.

What are the social predictors of accident and emergency attendance in disadvantaged neighbourhoods? Results from a cross-sectional household health survey in the north west of England.

OBJECTIVES: The aim of this study was to identify the most important determinants of accident and emergency (A&E) attendance in disadvantaged areas. DESIGN, SETTING AND PARTICIPANTS: A total of 3510 residents from 20 disadvantaged neighbourhoods in the North West Coast area in England completed a comprehensive public health survey. MAIN OUTCOME MEASURES: Participants were asked to complete general background information, as well as information about their physical health, mental health, lifestyle, social issues, housing and environment, work and finances, and healthcare service usage. Only one resident per household could take part in the survey. Poisson regression analysis was employed to assess the predictors of A&E attendance frequency in the previous 12 months. RESULTS: 31.6% of the sample reported having attended A&E in the previous 12 months, ranging from 1 to 95 visits. Controlling for demographic and health factors, not being in employment and living in poor quality housing increased the likelihood of attending an A&E service. Service access was also found to be predictive of A&E attendance insofar as there were an additional 18 fewer A&E attendances per 100 population for each kilometre closer a person lived to a general practitioner (GP) practice, and 3 fewer attendances per 100 population for each kilometre further a person lived from an A&E department. CONCLUSIONS: This is one of the first surveys to explore a comprehensive set of socio-economic factors as well as proximity to both GP and A&E services as predictors of A&E attendance in disadvantaged areas. Findings from this study suggest the need to address both socioeconomic issues, such as employment and housing quality, as well as structural issues, such as public transport and access to primary care, to reduce the current burden on A&E departments.