Shirt sponsorship by gambling companies in the English and Scottish Premier Leagues: global reach and public health concerns.

While the nature of gambling practices is contested, a strong evidence base demonstrates that gambling can become a serious disorder and have a range of detrimental effects for individuals, communities and societies. Over the last decade, football in the UK has become visibly entwined with gambling marketing. To explore this apparent trend, we tracked shirt sponsors in both the English and Scottish Premier Leagues since 1992 and found a pronounced increase in the presence of sponsorship by gambling companies. This increase occurred at the same time the Gambling Act 2005, which liberalized rules, was introduced. We argue that current levels of gambling sponsorship in UK football, and the global visibility it provides to gambling brands, is a public health concern that needs to be debated and addressed. We recommend that legislators revisit the relationship between football in the UK and the sponsorship it receives from the gambling industry.

A New Approach for Sampling Ordered Parameters in Probabilistic Sensitivity Analysis.

BACKGROUND: Probabilistic sensitivity analysis (PSA) in cost-effectiveness analysis involves sampling a large number of realisations of an economic model. For some parameters, we may be uncertain around the true mean values of the variables, but the ordering of the values is known. Typical sampling approaches lack either statistical or clinical validity. For example, sampling using a common number generator results in extreme dependence, and independent sampling can lead to realisations with incorrect ordering. METHODS: We propose a new sampling approach for ordered parameters, the difference method (DM) approach, which samples the parameters of interest via a difference parameter. If the parameters of interest are bounded, it involves transforming the variables so that they are unbounded and then sampling via the difference parameter. We have provided a Microsoft Excel workbook to implement the method. The proposed approach is illustrated with an example sampling ordered parameters for utility and cost. RESULTS: The DM approach has a number of advantages when comparing with the typical approaches used in practice. It generates PSA samples that have similar summary statistics as the given values in our examples, while maintaining the constraint that one value was greater than another. The method also implies plausible positive correlation between the two ordered variables. CONCLUSIONS: Both clinical and statistical validity should be checked when producing PSA samples. The DM approach should be considered as a solution to potential problems in generating PSA samples for ordered parameters.

Could the rise in mortality rates since 2015 be explained by changes in the number of delayed discharges of NHS patients?

BACKGROUND: 2015 saw the largest annual spike of mortality rates in England in almost 50 years. We examine whether these changes in mortality rates are associated with an indicator of poor functioning of health and social care: delay in hospital discharges. METHODS: Office for National Statistics monthly data of death counts and mortality rates for the period August 2010-March 2016 were compared with delays in discharges from National Health Service (NHS) England data on transfers of care for acute and non-acute patients in England. Autoregressive Integrated Moving Average regression models were used in the analysis. RESULTS: We estimate that each additional day an acute admission was late being discharged was associated with an increase in 0.394 deaths (95% CIs 0.220 to 0.569). For each additional acute patient delayed being discharged, we found an increase of 7.322 deaths (95% CIs 1.754 to 12.890). Findings for non-acute admissions were mixed. CONCLUSION: The increased prevalence of patients being delayed in discharge from hospital in 2015 was associated with increases in mortality, accounting for up to a fifth of mortality increases. Our study provides evidence that a lower quality of performance of the NHS and adult social care as a result of austerity may be having an adverse impact on population health.

Accuracy of point-of-care testing for circulatory cathodic antigen in the detection of schistosome infection: systematic review and meta-analysis.

OBJECTIVE: To assess the accuracy of point-of-care testing for circulatory cathodic antigen in the diagnosis of schistosome infection. METHODS: We searched MEDLINE, EMBASE, LILACS and other bibliographic databases for studies published until 30 September 2015 that described circulatory cathodic antigen testing compared against one to three Kato-Katz tests per subject - for Schistosoma mansoni - or the filtration of one 10-ml urine sample per subject - for S. haematobium. We extracted the numbers of true positives, false positives, true negatives and false negatives for the antigen testing and performed meta-analyses using a bivariate hierarchical regression model. FINDINGS: Twenty-six studies published between 1994 and 2014 met the inclusion criteria. In the detection of S. mansoni, a single antigen test gave a pooled sensitivity of 0.90 (95% confidence interval, CI: 0.84-0.94) and a pooled specificity of 0.56 (95% CI: 0.39-0.71; n = 7) when compared against a single Kato-Katz test. The corresponding values from comparisons with two to three Kato-Katz tests per subject were 0.85 (95% CI: 0.80-0.88) and 0.66 (95% CI: 0.53-0.76; n = 14), respectively. There appeared to be no advantage in using three antigen tests per subject instead of one. When compared against the results of urine filtration, antigen testing for S. haematobium showed poor sensitivity and poor specificity. The performance of antigen testing was better in areas of high endemicity than in settings with low endemicity. CONCLUSION: Antigen testing may represent an effective tool for monitoring programmes for the control of S. mansoni.

Visualising variation in mortality rates across the life course and by sex, USA and comparator states, 1933-2010.

BACKGROUND: Previous research showed that younger adult males in the USA have, since the 1950s, died at a faster rate than females of the same age. In this paper, we quantify this difference, and explore possible explanations for the differences at different ages and in different years. METHODS: Using data from the Human Mortality Database (HMD), the number of additional male deaths per 10 000 female deaths was calculated for each year from 1933 to 2010, and for each year of age from 0 to 60 years, for the USA, and a number of other countries for comparison. The data were explored visually using shaded contour plots. RESULTS: Gender differences in excess mortality have increased. Coming of age (between the ages of 15 and 25 years of age) is especially perilous for men relative to women now compared with the past in the USA; the visualisations highlight this change as important. CONCLUSIONS: Sex differences in mortality risks at various ages are not static. While women may today have an advantage when it comes to life expectancy, in the USA, this has greatly increased since the 1930s. Just as young adulthood for women has been made safer through safer antenatal and childbirth practices, changes in public policy can make the social environment safer for men.

Real geographies and virtual landscapes: exploring the influence on place and space on mortality Lexis surfaces using shaded contour maps.

This paper describes how shaded contour plots, applied to mortality data from the Human Mortality Database, can be used to compare between nations, and start to tease out some of the ways that place and space matters. A number of shaded contour plots are presented, in order to describe the age, period and cohort effects which are apparent within them. They show variations between different subpopulations within the same nation, over time, and between nations. In illustrating these intra- and international variations in the patterns, we hope to encourage the development of hypotheses about the influence of such factors on mortality rates. We conclude with a brief discussion about how such hypotheses might be developed into statistical models, allowing for more rigourous testing of hypotheses and projection across time, place and space.

A randomised controlled trial and cost-effectiveness evaluation of 'booster' interventions to sustain increases in physical activity in middle-aged adults in deprived urban neighbourhoods.

BACKGROUND: More evidence is needed on the potential role of 'booster' interventions in the maintenance of increases in physical activity levels after a brief intervention in relatively sedentary populations. OBJECTIVES: To determine whether objectively measured physical activity, 6 months after a brief intervention, is increased in those receiving physical activity 'booster' consultations delivered in a motivational interviewing (MI) style, either face to face or by telephone. DESIGN: Three-arm, parallel-group, pragmatic, superiority randomised controlled trial with nested qualitative research fidelity and geographical information systems and health economic substudies. Treatment allocation was carried out using a web-based simple randomisation procedure with equal allocation probabilities. Principal investigators and study statisticians were blinded to treatment allocation until after the final analysis only. SETTING: Deprived areas of Sheffield, UK. PARTICIPANTS: Previously sedentary people, aged 40-64 years, living in deprived areas of Sheffield, UK, who had increased their physical activity levels after receiving a brief intervention. INTERVENTIONS: Participants were randomised to the control group (no further intervention) or to two sessions of MI, either face to face ('full booster') or by telephone ('mini booster'). Sessions were delivered 1 and 2 months post-randomisation. MAIN OUTCOME MEASURES: The primary outcome was total energy expenditure (TEE) per day in kcal from 7-day accelerometry, measured using an Actiheart device (CamNtech Ltd, Cambridge, UK). Independent evaluation of practitioner competence was carried out using the Motivational Interviewing Treatment Integrity assessment. An estimate of the per-participant intervention costs, resource use data collected by questionnaire and health-related quality of life data were analysed to produce a range of economic models from a short-term NHS perspective. An additional series of models were developed that used TEE values to estimate the long-term cost-effectiveness. RESULTS: In total, 282 people were randomised (control = 96; mini booster = 92, full booster = 94) of whom 160 had a minimum of 4 out of 7 days' accelerometry data at 3 months (control = 61, mini booster = 47, full booster = 52). The mean difference in TEE per day between baseline and 3 months favoured the control arm over the combined booster arm but this was not statistically significant (-39 kcal, 95% confidence interval -173 to 95, p = 0.57). The autonomy-enabled MI communication style was generally acceptable, although some participants wanted a more paternalistic approach and most expressed enthusiasm for monitoring and feedback components of the intervention and research. Full boosters were more popular than mini boosters. Practitioners achieved and maintained a consistent level of MI competence. Walking distance to the nearest municipal green space or leisure facilities was not associated with physical activity levels. Two alternative modelling approaches both suggested that neither intervention was likely to be cost-effective. CONCLUSIONS: Although some individuals do find a community-based, brief MI 'booster' intervention supportive, the low levels of recruitment and retention and the lack of impact on objectively measured physical activity levels in those with adequate outcome data suggest that it is unlikely to represent a clinically effective or cost-effective intervention for the maintenance of recently acquired physical activity increases in deprived middle-aged urban populations. Future research with middle-aged and relatively deprived populations should explore interventions to promote physical activity that require less proactive engagement from individuals, including environmental interventions. STUDY REGISTRATION: Current Controlled Trials ISRCTN56495859, ClinicalTrials.gov NCT00836459. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 13. See the NIHR Journals Library website for further project information.

Exploring the relationship between baseline physical activity levels and mortality reduction associated with increases in physical activity: a modelling study.

BACKGROUND: Increasing physical activity (PA) levels among the general adult population of developed nations is important for reducing premature mortality and the burdens of preventable illness. Assessing how effective PA interventions are as health interventions often involves categorising participants as either 'active' or 'sedentary' after the interventions. A model was developed showing that doing this could significantly misestimate the health effect of PA interventions. METHODS: A life table model was constructed combining evidence on baseline PA levels with evidence indicating the non-linear relationship between PA levels and all-cause mortality risks. PA intervention scenarios were modelled which had the same mean increase in PA but different levels of take-up by people who were more active or more sedentary to begin with. RESULTS: The model simulations indicated that, compared with a scenario where already-active people did most of the additional PA, a scenario where the least active did the most additional PA was around a third more effective in preventing deaths between the ages of 50 and 60 years. The relationship between distribution of PA take-up and health effect was explored systematically and appeared non-linear. CONCLUSIONS: As the health gains of a given PA increase are greatest among people who are most sedentary, smaller increases in PA in the least active may have the same health benefits as much larger PA increases in the most active. To help such health effects to be assessed, PA studies should report changes in the distribution of PA level between the start and end of the study.

Visualizing Europe's demographic scars with coplots and contour plots.

We present two enhancements to existing methods for visualizing vital statistics data. Data from the Human Mortality Database were used and vital statistics from England and Wales are used for illustration. The simpler of these methods involves coplotting mean age of death with its variance, and the more complex of these methods is to present data as a contour plot. The coplot method shows the effect of the 20th century's epidemiological transitions. The contour plot method allows more complex and subtle age, period and cohort effects to be seen. The contour plot shows the effects of broad improvements in public health over the 20th century, including vast reductions in rates of childhood mortality, reduced baseline mortality risks during adulthood and the postponement of higher mortality risks to older ages. They also show the effects of the two world wars and the 1918 influenza pandemic on men of fighting age, women and children. The contour plots also show a cohort effect for people born around 1918, suggesting a possible epigenetic effect of parental exposure to the pandemic which shortened the cohort's lifespan and which has so far received little attention. Although this article focuses on data from England and Wales, the associated online appendices contain equivalent visualizations for almost 50 series of data available on the Human Mortality Database. We expect that further analyses of these visualizations will reveal further insights into global public health.

Health, employment, and economic change, 1973-2009: repeated cross sectional study.

OBJECTIVE: To see whether adverse relations between social class, health, and economic activity, observed between 1973 and 1993 and previously identified in a 1996 BMJ paper, were still apparent between 1994 and 2009 despite improvements in the general economic climate and overall population health. DESIGN: Replication of repeated cross sectional analysis from the original paper, using the same source (the General Household Survey) and occupation coding scheme, but extended from the period 1973-93 to 1973-2009, and including women as well as men. SUBJECTS: Men and women aged 20-59 years in each annual survey between 1973 and 2009. MAIN OUTCOME MEASURES: Change over time in class specific rates of employment, unemployment, and economic inactivity within subgroups of respondents. RESULTS: Overall employment rates have decreased for men of working age while increasing for working age women. For men in particular, the gradient of these changes seems to depend on occupational group. Over 37 years, the differences in occupational group specific economic inactivity and employment rates between people reporting and those not reporting a limiting long term illness has increased substantially. CONCLUSION: Between 1973 and 2009, the relation between good health and securing and sustaining employment has strengthened for both men and women. For men, this has been due to employment rates decreasing and economic inactivity rates increasing among men with poor health. For women, this has largely been due to a general trend of increased employment and reduced economic inactivity occurring among healthier women but not in women of poorer health. Some evidence suggests that, since 2005, the relation between health, employment, and economic inactivity for women in the top two occupational groups has become more like that for men, with poor health becoming associated with reducing employment rates.