PURPOSE:People experiencing marginalisation are over-represented in the criminal justice system (CJS) worldwide. CJS involvement exacerbates health and care inequalities, with poorer outcomes amongst people released from prison. Fragmented care and support persist upon release, but little is known about how health and justice systems intersect. The aim of this systematic review was to synthesise global evidence on: 1) integration of health and justice systems focused on people's experiences of returning to their community after prison; 2) the impact of CJS involvement on health, and care inequalities. METHODS:Six databases (MEDLINE, EMBASE, PsycINFO, CINHAL, ASSIA and Scopus) were searched for primary studies, of any design, conducted from 2013 onwards. Using a mixture of controlled search vocabulary (e.g. MeSH) and free text, search terms were derived using the SPIDER framework. All empirical studies were included which contained data relating to system links between CJS settings and the community which impacted on health in OECD countries. Thematic analysis was used to identify common themes across extracted data. RESULTS:20,104 studies were initially identified and screened for inclusion, with 43 included in the review. Our synthesis of the literature demonstrates that the CJS can have a considerable detrimental impact on health. We identified five themes: 1. (In)equivalence of healthcare in prison; 2. Public health interventions which bridge the gap from prison to the community; 3. Discontinuities in care and system-level precarity; 4. Social determinants of health impeding resettlement; 5. Elements of successful resettlement after prison: bridging the gap. CONCLUSIONS:The identified themes show how marginalised, justice-involved populations are at a greater risk of experiencing detrimental health and care where health and justice systems fail to connect. We highlight the need for system level data sharing; cultural competency; and clarity in the role of 'resettlement hubs' in bridging the gap.

Background Type 2 diabetes is linked to a high prevalence of oral health problems, but whether poor oral health contributes to diabetes risk remains unclear. This study examined the association between various oral health markers and the incidence of type 2 diabetes. Methods Data were derived from the British Regional Heart Study cohort of men aged 71–92 years (n=2147) across 24 UK towns. Oral health markers included tooth count, periodontal disease, dry mouth, self-rated oral health, denture use, and associated difficulties. Participants were followed for 8 years (2010–2018) for diabetes incidence using General Practice records. Cox regression models adjusted for age, BMI, social class, smoking, alcohol use, physical activity, and medical history. Results Among 1908 men without diabetes at baseline, 78 developed diabetes during follow-up. Significant associations with diabetes risk were observed for complete tooth loss (Hazard ratio (HR)=4.03, 95% Confidence Interval (CI) =1.83–8.86), poor/fair self-rated oral health (HR=2.63, 95% CI=1.50–4.62), denture use or no dentures among those with no natural teeth (HR=2.91, 95% CI=1.36–6.22), and having ≥2 oral health problems causing difficulty in daily tasks (HR=3.10, 95% CI=1.27–7.55). Conclusion Poor oral health, including tooth loss, poor self-rated oral health, and difficulties associated with oral health problems, was significantly linked to an increased risk of developing type 2 diabetes in older adults. Further research is needed to clarify the underlying mechanisms and explore whether improving oral health can reduce the risk of diabetes in older men.

Periodontal disease, an inflammatory condition affecting the tissue surrounding the teeth, has been associated with various systemic health issues. Dietary nitrate and nitrite are found in a range of plant and animal foods and, depending upon source, have been linked with both positive and negative health effects, including improved oral health with plant sources. This study aimed to investigate the associations between source-dependent (plant- and animal-sourced) nitrate and nitrite intake and odds of periodontal disease. We explored cross-sectional and longitudinal associations between tertiles of source-dependent nitrate and nitrite intake and the odds of periodontal disease using multivariable logistic regression models (cross-sectional analyses) and generalised estimating equations (longitudinal analyses) in 158,778 and 83,026 participants, respectively, from the UK Biobank. Dietary nitrate/nitrite intake was estimated from 24 h dietary assessments and a comprehensive food composition database. Higher intake of plant-derived nitrate was associated with significantly lower odds of periodontal disease in cross-sectional (OR [95

BACKGROUND:Increasing demand for General Practice (GP) services has led to new ways of working being explored to ease pressures on healthcare access. Community pharmacists (CPs) play a key role to help with this and can deliver disease prevention interventions. AIMS:To explore the views of CP's, serving communities/neighbourhoods experiencing high levels of socioeconomic disadvantage and ill-health on taking a role in the prevention of chronic disease. DESIGN & SETTING:Three areas in England (North-East and North Cumbria, Greater Manchester and Sheffield) METHOD: Semi-structured interviews with 16 CPs. These were transcribed and analysed in accordance with the principles of reflexive thematic analysis. Themes were identified, discussed and agreed. RESULTS:Key themes identified included: time and financial pressures, integration of services and communication, and training and confidence. While CPs were positive about expanding their role and believed that the requisite trust was established with their community. There were significant reservations about taking on new roles without appropriate training and remuneration. Practical issues around communication with GPs, access to patient records and having the time to perform new duties were highlighted. CONCLUSIONS:CPs serving deprived populations see themselves as being well positioned to contribute to chronic disease prevention. Realising this potential requires systematic change. Significant barriers have been identified that reflect the complexity of serving deprived communities. Without addressing these structural barriers, expanding pharmacy roles risks creating unsustainable expectations and potentially widening health inequalities. The development of a Deep End pharmacy network could provide a platform to collectively explore these challenges.

This cohort study evaluates whether socioeconomic factors, including sex, race and ethnicity, material deprivation, and rurality) are associated with the age at which patients are diagnosed with severe mental illness.

Objective This study investigated the association of poor oral health with appetite loss and deterioration in appetite longitudinally in older adults. Design Cross-sectional and longitudinal observational study. Setting Data came from two population-based cohorts of older adults from the UK and USA. Participants The British Regional Heart Study (BRHS) included men (n=1348, age=79-87 years in 2016-2017 at baseline and 81-89 years in 2018-2019 at follow-up). The US Health, Aging and Body Composition (HABC) Study included men and women (n=2998, age=71-77 years in 1998-1999 at baseline and 73-79 years in 2000-2001 at follow-up). Objective and self-reported oral health measures were collected. Outcome measures Loss of appetite, at baseline and 2-year follow-up, was based on the Simplified Nutrition Assessment Questionnaire in the BRHS and self-reported appetite loss in the HABC Study. In the BRHS, changes in oral health over time were also assessed. Logistic regression models were adjusted for sociodemographic, behavioural and health-related factors. Results Cross-sectionally, poor self-rated oral health, dry mouth, eating or chewing difficulty, food avoidance and cumulative oral health problems were associated with appetite loss in both studies. Longitudinally, in the BRHS, dry mouth (OR=2.12 (95% CI=1.40 to 3.20)), eating or chewing difficulty (OR=1.59 (95% CI=1.02 to 2.48)), food avoidance (OR=1.75 (95% CI=1.16 to 2.65)) and cumulative oral health problems (OR=2.84 (95% CI=1.80 to 4.50)) at baseline were associated with sustained poor/deterioration in appetite over the follow-up, after full adjustment. In the HABC Study, self-rated oral health ((OR=1.13 (95% CI=1.01 to 1.27)), tooth loss (OR=1.78 (95% CI=1.15 to 2.76)), dry mouth (OR=1.76 (95% CI=1.02 to 3.03)), eating or chewing difficulty (OR=1.88 (95% CI=1.41 to 2.50)) and cumulative oral health problems (OR=1.89 (95% CI=1.33 to 2.70)) at baseline were associated with sustained poor/deterioration in appetite during follow-up. In the BRHS, sustained poor/deterioration in oral health markers (self-rated oral health, dry mouth, eating or chewing difficulty, food avoidance, loose denture/s) over the follow-up were associated with sustained poor/deterioration of appetite. Conclusion Oral health is a potentially important contributor to maintaining good appetite in older age.

ABSTRACTObjectivePublic Involvement (PI) in applied health and social care research has grown exponentially in the UK. This review aims to synthesise published UK evidence that evaluates the process and/or outcome(s) of PI in applied health and social care research to identify key contextual factors, effective strategies, outcomes and public partner experiences underpinning meaningful PI in research.MethodsFollowing a pre‐registered protocol, we systematically searched four databases and two key journals for studies conducted within the UK between January 2006 and July 2024. A team of public partners and researchers carried out independent dual screening and data extraction. Included studies were narratively synthesised via Framework Synthesis.ResultsNineteen studies evaluated the PI process with a range of populations including National Health Service (NHS) users, carers, and low‐income communities. No specific outcome evaluations were identified. Through their experience, public partners described important components of meaningful PI such as mutual respect and seeing and contributing to change, as well as some unintended harms of involvement. Harms related to ‘experiencing negative attitudes’, ‘emotional burden of involvement’, ‘frustration and disappointment’ and ‘further marginalisation’. Meaningful PI was underpinned by structural, organisational, interpersonal and individual factors; as well as practical and principle‐based strategies of involvement. Both public partners and researchers reflected on a range of outcomes of meaningful PI including changes to the research process and longer term impacts on organisations, researchers and public partners.ConclusionsPI in research must be facilitated at multiple levels to reduce unintended harm and encourage meaningful and impactful outcomes. Findings are summarised within a model which gives an overview of priorities for individual researchers, organisations and funders to ensure best practice is achievable. From a methodological perspective, researchers should prioritise robust, transparent and co‐produced approaches to evaluating PI to increase knowledge in the field.Patient and Public InvolvementA regional public advisory network provided insight on the relevance and acceptability of the review concept. Our core research team included three public partners. Public partners contributed to the development of the initial review protocol, abstract and full‐text screening, reviewing findings and their interpretation and writing the final report.

[This corrects the article DOI: 10.1016/j.eclinm.2024.102662.].

Drawing on several studies, this chapter explores the potential application of trauma-informed principles in meaningful involvement and engagement with people who experience(d) homelessness and trauma. The chapter starts with exploring trauma and contemporary trauma theory and co-production in research to set the context. In this chapter, we draw on key issues related to trauma and homelessness to explore the application and practical strategies for undertaking research. Particular aspects include acknowledging past and current experiences of trauma while preventing re-stigmatisation and ensuring meaningful involvement. We suggest that concerns with safety, trustworthiness and transparency, collaboration and mutuality, peer support, empowerment, voice and choice, and cultural, historical and gender issues need to be considered in the context of involvement and engagement. This chapter concludes with considering the need for ongoing reflective practice, which will ensure that researchers can maintain an awareness and understanding of trauma and its consequences, while ensuring meaningful and positive involvement in research takes place.

Social connections may impact the dynamic trajectory of frailty. Using data from the British Regional Heart Study (BRHS) in the UK (n = 715) and the US Health, Aging and Body Composition (Health ABC) Study (n = 1256), we conducted multinominal regression analyses to examine the association of baseline and change in social engagement and loneliness with progression to prefrailty and frailty, as well as their association with reversal to prefrailty and robust status among older adults. A higher level of social engagement at baseline (BRHS: relative risk ratio [RRR] 0.69 [95% CI, 0.55-0.85]; Health ABC: 0.56 [0.45-0.70]) and an increase in social engagement (BRHS: 0.73 [0.59-0.90]; Health ABC: 0.51 [0.41-0.63]) were associated with a lower risk of developing frailty. In BRHS, a higher level of loneliness at baseline (1.42 [1.10-1.83]) and an increase in loneliness (1.50 [1.18-1.90]) raised the risk of developing frailty. For reversal of frailty, higher social engagement at baseline (Health ABC: 1.63 [1.08-2.47]) and an increase in social engagement (BRHS: 1.74 [1.18-2.50]; Health ABC: 1.79 [1.17-.274]) were beneficial. Social connections may be potentially important and modifiable factors in both preventing and reversing progression of frailty in older adults.

Aims: High smoking rates and deprivation levels in the North East of England have led to an opportunity to pilot a tobacco dependency treatment offer for NHS (National Health Service) staff who smoke, to make a supported quit attempt. The direct and indirect benefits to staff, patients, and NHS organisations are well documented. This study aimed to evaluate service acceptability. Methods: The service included up to 12 weeks of free nicotine replacement therapy (NRT) and/or a refillable e-cigarette, motivational support, and premium access to the Smoke-Free app. The service evaluation used a mixed-methods design, combining the Theoretical Framework of Acceptability (TFA) questionnaire and semi-structured interviews with staff who had accessed the offer. The quantitative data were analysed using descriptive statistics and qualitative data via thematic analysis. Results: Sixty-eight survey responses reflected high acceptability and revealed four themes relating to the service familiarity and ease of access, suitability of the NRT/E-liquid ordering service, the vape kit, and behavioural support. Conclusions: The service was deemed highly acceptable, and service users’ experiences informed recommendations for improving future tobacco dependency services. This is the first known application of the TFA to an evaluation of a smoking cessation intervention, and it contributes to a broader body of research on reducing tobacco dependency.

BACKGROUND:The 'Everyone In' national policy initiative launched in England during the COVID- 19 pandemic provided accommodation and health and care support to people who were (or at risk of) sleeping rough. This study aims to understand what worked well and less well in implementing 'Everyone In' for improving physical and mental health outcomes for people experiencing homelessness. METHODS:Between January and October 2023, in-depth interviews/focus groups were conducted across England with those involved in the delivery/implementation of 'Everyone In' and those accommodated. Framework analysis and case study analysis were used for a contextual understanding of the implementation of the policy initiative. RESULTS:Twenty-five people accommodated through 'Everyone In' (28-58 years; 88% males) and 43 service providers (25-62 years; 40% males) were interviewed. Flexibility in funding and resources, 'joining up' services/support, and innovative responsiveness in services across health, care, and housing systems were key positive features of the initiative. In the long term, 'Everyone In' has provided positive learnings for delivering holistic and integrated health and social care. It has also highlighted the importance of accommodating psychosocial needs and addressing the complexities of alcohol and substance use in all homelessness strategies. CONCLUSIONS:Pathways to care for people experiencing homelessness need to be flexible and responsive. Complexities such as substance use need to be approached with compassion while addressing the role of wider determinants in such health behaviours. Innovative approaches and joined-up work improve delivery of interventions and integrated care can reduce barriers to access to support.

People experiencing homelessness have often faced both historical and ongoing trauma, which can be compounded by their interactions with different support services. Trauma-informed care aims to meet the complex needs of people who have experienced trauma and prevent re-traumatisation during service interactions. In rural and coastal areas, where services are often geographically dispersed, multi-agency approaches are particularly crucial for ensuring continuous, coordinated support. This study examines the learning from implementing a multi-agency trauma-informed training pilot for providers supporting people experiencing homelessness. A qualitative study was undertaken following a trauma-informed care training pilot delivered to health and social care providers in Northumberland and North Tyneside, two geographically diverse rural and coastal areas in North East England. Those who attended the training were invited to take part in follow-up semi-structured interviews, thirteen out of 16 attendees participated, representing healthcare, emergency care, housing, voluntary sector, and social care services. Interviews explored how training influenced trauma-informed practice and cross-service collaboration. Interviews highlighted the value that participants of the training found in bringing different services together for undertaking trauma-informed training, and the opportunity for shared learning amongst those who provide care for people with multiple needs and interacting with different services. Three key themes were identified from the thematic analysis: (1) training cultivated awareness, sensitivity and compassion in communication across services (2) the need to foster support and trauma sensitivity through multi-agency collaboration and wider-system engagement and (3) building organisational and individual resilience through shared learning and coordinated supportive practices. Multi-agency trauma-informed training helps ensure consistent approaches across geographically dispersed services supporting people experiencing homelessness. When staff from different organisations train together, it builds a shared understanding of trauma, encourages collaborative working, and supports staff wellbeing. This integrated approach is particularly valuable in rural and coastal areas where service coordination can be challenging due to geographical dispersion and resource constraints.

Background:Autistic adults are at greater risk of self-harm and suicide than the general population. One promising intervention in the general population is safety planning. We aimed to seek advice from autistic adults and others in the autism community on how to adapt safety plans for autistic adults. Methods:We conducted focus groups with autistic adults (n = 15), family members (n = 5), and service providers (n = 10), about their views of the Autism Adapted Safety Plan (AASP). We also conducted interviews about the acceptability of the AASP with autistic adults who had developed an AASP (n = 8) and with service providers who had supported them (n = 8). We analyzed the focus group and interview transcripts using thematic analysis. Results:Theme 1 highlights conditions needed to make the process of creating the AASP acceptable for autistic adults. This included creating the AASP with someone they could trust and at the right place and time, when they were not in distress or in crisis. Theme 2 describes how safety planning needed to be a creative, flexible, and iterative process. Autistic adults may need help in expressing their emotions and identifying coping strategies, which can be supported through visual resources and suggestions from the service provider. To ensure that the AASP is accessible in times of crisis, it needs to meet the autistic adults' preferences in terms of formatting and how it is stored (i.e., hard copy or electronic). Conclusions:The AASP is a potentially valuable intervention for autistic adults, provided that the process of creating it is flexible and sensitive to individual needs. Further testing of the AASP to assess its clinical effectiveness in reducing suicidal behavior could provide a life-saving intervention for autistic adults. Clinical Trial Registration Number:ISRCTN70594445, Protocol v4: 8/2/22.

Background Autism Adapted Safety Plans (AASP) have been proposed to help prevent self-harm and suicidality among autistic adults. The introduction of such plans not only needs to be clinically effective but also cost-effective. The aim of this work was to establish how the cost-effectiveness of AASP could be assessed. Specifically, whether tools and techniques used to collect data for health economic evaluation of the intervention are feasible and acceptable to autistic people. Methods A feasibility and external pilot randomised controlled trial of the AASP intervention was conducted. Autistic adults recruited from diverse locations in England and Wales were randomised to either: AASP and usual care, or usual care only. Health economics tools (bespoke and adapted) were developed and focus groups were undertaken with participants, including autistic adults ( n = 15), their family members/carers ( n = 5), and service providers ( n = 10), to determine their acceptability and feasibility. Tools considered worth further exploration were interviewer administered to participants during the pilot trial at baseline and at 6 months. Interviewer notes were used to record any issues reported while completing the tools. Response rates on the questions and completeness of the tools, along with participant feedback in the interviewer notes was assessed. Results Standard Gamble and Time-Trade Off approaches to measure health status were judged inappropriate to measure health outcomes with autistic adults experiencing suicidal ideation and with a history of self-harm. Contingent valuation and discrete choice experiments were also considered inappropriate, due to the heavy cognitive burden on respondents. The EQ-5D-5L/VAS, resource utilisation questionnaire and time-travel questionnaire were considered acceptable by participants. Response and completion rates (as a percentage of all returned questionnaires) for resource utilisation questionnaire (> 85%), time-travel questionnaire (> 79%), EQ-5D-5L (> 96%) and EQ-5D-VAS (> 87%) were good in general. Participants needed clear guidance and interviewer support to enable questionnaire completion. Conclusions It is feasible and acceptable to collect relevant data on resource utilisation, and costs of accessing care and the EQ-5D-5L in a future definitive trial. Clear guidance and interviewer support on how to complete the questionnaires and explanations of the importance of questions to the research would help autistic participants completing the health economic tools. Trial registration ISRCTN70594445; Trial Registration Date: 06/07/2020.

People experiencing homelessness often face challenges accessing health and social care services, prompting reliance on emergency care services. This study aimed to characterize the health needs of people experiencing homelessness seeking emergency care in rural and coastal areas of North East England. Data from emergency care facilities in Northumberland and North Tyneside areas of North East England were analysed for the period between 1 February 2019 and 31 March 2022. Homelessness was identified using hospital records, and participant characteristics (age, gender, ethnicity) and health details (repeat attendances, diagnoses, and underlying co-morbidities) were analysed descriptively. 260 homeless individuals made 567 visits to emergency departments over three years, with 55% being repeat attendances within 12 months. Most were male (83%) with a mean age of 39 years, 32% of attendances had multiple diagnoses, with poisoning, psychiatric disorders, and social issues being the most common diagnoses. People experiencing homelessness in rural coastal areas of North East England present at emergency care services with issues related to drugs, alcohol, mental health, and social care, along with high levels of co-morbidities. These findings highlight the complexity of their needs, which need to be addressed outside of emergency care.