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ObjectivesTo quantify the effect of the COVID-19 pandemic on the timeliness of, and geographical and sociodemographic inequalities in, receipt of first measles, mumps and rubella (MMR) vaccination.DesignLongitudinal study using primary care electronic health records.Setting285 general practices in North East London.ParticipantsChildren born between 23 August 2017 and 22 September 2018 (pre-pandemic cohort) or between 23 March 2019 and 1 May 2020 (pandemic cohort).Main outcome measureReceipt of timely MMR vaccination between 12 and 18 months of age.MethodsWe used logistic regression to estimate the ORs (95% CIs) of receipt of a timely vaccination adjusting for sex, deprivation, ethnic background and Clinical Commissioning Group. We plotted choropleth maps of the proportion receiving timely vaccinations.ResultsTimely MMR receipt fell by 4.0% (95% CI: 3.4% to 4.6%) from 79.2% (78.8% to 79.6%) to 75.2% (74.7% to 75.7%) in the pre-pandemic (n=33 226; 51.3% boys) and pandemic (n=32 446; 51.4%) cohorts, respectively. After adjustment, timely vaccination was less likely in the pandemic cohort (0.79; 0.76 to 0.82), children from black (0.70; 0.65 to 0.76), mixed/other (0.77; 0.72 to 0.82) or with missing (0.77; 0.74 to 0.81) ethnic background, and more likely in girls (1.07; 1.03 to 1.11) and those from South Asian backgrounds (1.39; 1.30 to 1.48). Children living in the least deprived areas were more likely to receive a timely MMR (2.09; 1.78 to 2.46) but there was no interaction between cohorts and deprivation (Wald statistic: 3.44; p=0.49). The proportion of neighbourhoods where less than 60% of children received timely vaccination increased from 7.5% to 12.7% during the pandemic.ConclusionsThe COVID-19 pandemic was associated with a significant fall in timely MMR receipt and increased geographical clustering of measles susceptibility in an area of historically low and inequitable MMR coverage. Immediate action is needed to avert measles outbreaks and support primary care to deliver timely and equitable vaccinations.

Maternity care has to be available 24 hours a day, seven days a week. It is known that obstetric intervention can influence the time of birth, but no previous analysis at a national level in England has yet investigated in detail the ways in which the day and time of birth varies by onset of labour and mode of giving birth. We linked data from birth registration, birth notification, and Maternity Hospital Episode Statistics and analysed 5,093,615 singleton births in NHS maternity units in England from 2005 to 2014. We used descriptive statistics and negative binomial regression models with harmonic terms to establish how patterns of timing of birth vary by onset of labour, mode of giving birth and gestational age. The timing of birth by time of day and day of the week varies considerably by onset of labour and mode of birth. Spontaneous births after spontaneous onset are more likely to occur between midnight and 6am than at other times of day, and are also slightly more likely on weekdays than at weekends and on public holidays. Elective caesarean births are concentrated onto weekday mornings. Births after induced labours are more likely to occur at hours around midnight on Tuesdays to Saturdays and on days before a public holiday period, than on Sundays, Mondays and during or just after a public holiday. The timing of births varies by onset of labour and mode of birth and these patterns have implications for midwifery and medical staffing. Further research is needed to understand the processes behind these findings.

BackgroundChildren with obesity at school entry are at increased risk of persistent obesity throughout childhood and adulthood. Little is known about associations with adverse health outcomes with onset during childhood including those affecting the musculoskeletal system. We examined the association between obesity present at school entry and adverse musculoskeletal diagnoses with onset during childhood.MethodsWe searched three electronic databases to identify longitudinal studies published in English between January 2000 and June 2022 assessing associations between obesity measured at school entry (around age 5 years) and musculoskeletal diagnoses made before age 20 years. Two reviewers screened titles, abstracts and full-text using EPPI-Reviewer software. Bias and quality of eligible studies were appraised using The Quality Assessment tool for Observational Cohort and Cross-sectional studies and findings synthesised.ResultsWe identified four eligible studies from 291 unique records, three conducted in Spain and one in Scotland. These studies reported on 1 232 895 children (available data: 51.4% boys; none reported ethnic distribution) with study sample sizes ranging from <2000 to 600 000 and length of follow-up from 2 to 13 years. Quantitative synthesis of findings across these four studies was not possible due to differences in outcomes and effect sizes reported. Children with obesity at school entry were more likely to receive diagnoses of slipped capital femoral epiphysis, back pain, fractures and musculoskeletal complaints made in primary care settings. Included studies were assessed as of ‘fair’ to ‘good’ quality.ConclusionThere is good to fair evidence to suggest children with obesity at school entry are more likely to receive a diagnosis of a musculoskeletal condition during childhood. Further research is needed to replicate these findings in ethnically diverse populations and to investigate whether these are causal associations. The implications of this for children’s mobility and quality of life and future musculoskeletal health warrants further assessment.

There is still limited understanding of how chronic conditions co-occur in patients with multimorbidity and what are the consequences for patients and the health care system. Most reported clusters of conditions have not considered the demographic characteristics of these patients during the clustering process. The study used data for all registered patients that were resident in Fife or Tayside, Scotland and aged 25 years or more on 1st January 2000 and who were followed up until 31 st December 2018. We used linked demographic information, and secondary care electronic health records from 1 st January 2000. Individuals with at least two of the 31 Elixhauser Comorbidity Index conditions were identified as having multimorbidity. Market basket analysis was used to cluster the conditions for the whole population and then repeatedly stratified by age, sex and deprivation. 318,235 individuals were included in the analysis, with 67,728 (21·3%) having multimorbidity. We identified five distinct clusters of conditions in the population with multimorbidity: alcohol misuse, cancer, obesity, renal failure, and heart failure. Clusters of long-term conditions differed by age, sex and socioeconomic deprivation, with some clusters not present for specific strata and others including additional conditions. These findings highlight the importance of considering demographic factors during both clustering analysis and intervention planning for individuals with multiple long-term conditions. By taking these factors into account, the healthcare system may be better equipped to develop tailored interventions that address the needs of complex patients.

Background/objectivesWe identified household members from electronic health records linked to National Child Measurement Programme (NCMP) data to estimate the likelihood of obesity among children living with an older child with obesity.MethodsWe included 126 829 NCMP participants in four London boroughs and assigned households from encrypted Unique Property Reference Numbers for 115 466 (91.0%). We categorised the ethnic-adjusted body mass index of the youngest and oldest household children (underweight/healthy weight <91st, ≥91st overweight <98th, obesity ≥98th centile) and estimated adjusted ORs and 95% CIs of obesity in the youngest child by the oldest child’s weight status, adjusting for number of household children (2, 3 or ≥4), youngest child’s sex, ethnicity and school year of NCMP participation.ResultsWe identified 19 702 households shared by two or more NCMP participants (% male; median age, range (years)—youngest children: 51.2%; 5.2, 4.1–11.8; oldest children: 50.6%; 10.6, 4.1–11.8). One-third of youngest children with obesity shared a household with another child with obesity (33.2%; 95% CI: 31.2, 35.2), compared with 9.2% (8.8, 9.7) of youngest children with a healthy weight. Youngest children living with an older child considered overweight (OR: 2.33; 95% CI: 2.06, 2.64) or obese (4.59; 4.10, 5.14) were more likely to be living with obesity.ConclusionsIdentifying children sharing households by linking primary care and school records provides novel insights into the shared weight status of children sharing a household. Qualitative research is needed to understand how food practices vary by household characteristics to increase understanding of how the home environment influences childhood obesity.

IntroductionMultimorbidity is widely recognised as the presence of two or more concurrent long-term conditions, yet remains a poorly understood global issue despite increasing in prevalence.We have created the Wales Multimorbidity e-Cohort (WMC) to provide an accessible research ready data asset to further the understanding of multimorbidity. Our objectives are to create a platform to support research which would help to understand prevalence, trajectories and determinants in multimorbidity, characterise clusters that lead to highest burden on individuals and healthcare services, and evaluate and provide new multimorbidity phenotypes and algorithms to the National Health Service and research communities to support prevention, healthcare planning and the management of individuals with multimorbidity.Methods and analysisThe WMC has been created and derived from multisourced demographic, administrative and electronic health record data relating to the Welsh population in the Secure Anonymised Information Linkage (SAIL) Databank. The WMC consists of 2.9 million people alive and living in Wales on the 1 January 2000 with follow-up until 31 December 2019, Welsh residency break or death. Published comorbidity indices and phenotype code lists will be used to measure and conceptualise multimorbidity.Study outcomes will include: (1) a description of multimorbidity using published data phenotype algorithms/ontologies, (2) investigation of the associations between baseline demographic factors and multimorbidity, (3) identification of temporal trajectories of clusters of conditions and multimorbidity and (4) investigation of multimorbidity clusters with poor outcomes such as mortality and high healthcare service utilisation.Ethics and disseminationThe SAIL Databank independent Information Governance Review Panel has approved this study (SAIL Project: 0911). Study findings will be presented to policy groups, public meetings, national and international conferences, and published in peer-reviewed journals.

ObjectiveTo assess whether there is a higher incidence of musculoskeletal consultations in general practice among children with obesity.DesignLongitudinalSetting285 north-east London general practitioners (GPs).Participants63 418 (50.9% boys) Reception and 55 364 (50.8% boys) Year 6 National Child Measurement Programme (NCMP) participants, linked to GP electronic health records (EHRs).Main outcome measureA GP consultation with a recorded musculoskeletal symptom or diagnosis.MethodsWe calculated proportions with a musculoskeletal consultation by ethnic-adjusted weight status (underweight <2nd; overweight ≥91st; obese ≥98th centile), sex, ethnicity, and area-level deprivation. We estimated mutually-adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) using Cox’s proportional regression models stratified by school year and sex.ResultsWe identified 1868 (3.0%) Reception and 4477 (8.1%) Year 6 NCMP participants with at least one musculoskeletal consultation. In adjusted analyses, Reception year girls with a body mass index (BMI) classified as overweight (HR 1.24, 95% CI 1.02 to 1.52) or obese (HR 1.67, 95% CI 1.35 to 2.06) were more likely to have at least one musculoskeletal consultation. Year 6 girls with obesity were more likely (HR 1.20, 95% CI 1.07 to 1.35), and boys with a BMI in the underweight range were less likely (HR 0.39, 95% CI 0.21 to 0.73), to have a musculoskeletal consultation.ConclusionsGirls living with obesity at the start or end of primary school are more likely to attend their GP for a musculoskeletal consultation. Routine linkage of NCMP data to EHRs provides useful insights into childhood health conditions related to excess weight in early childhood. Recognition of obesity as a contributing factor for musculoskeletal symptoms may inform clinical management, particularly in girls.

Asthma has the potential to adversely affect children's school examination performance, and hence longer term life chances. Asthma morbidity is especially high amongst UK ethnic minority children and those experiencing social adversity, populations which also have poor educational outcomes. We tested the hypothesis that asthma adversely affects performance in national school examinations in a large cohort from an area of ethnic diversity and social deprivation. With a novel method (using patient and address-matching algorithms) we linked administrative and clinical data for 2002-2005 for children in east London aged 5-14 years to contemporaneous education and social care datasets. We modelled children's performance in school examinations in relation to socio-demographic and clinical variables. The dataset captured examination performance for 12,136 children who sat at least one national examination at Key Stages 1-3. For illustration, estimates are presented as percentage changes in Key Stage 2 results. Having asthma was associated with a 1.1% increase in examination scores (95%CI 0.4 to 1.7)%,p = 0.02. Worse scores were associated with Bangladeshi ethnicity -1.3%(-2.5 to -0.1)%,p = 0.03; special educational need -14.6%(-15.7 to -13.5)%,p = 0.02; mental health problems -2.5%(-4.1 to -0.9)%,p = 0.003, and social adversity: living in a smoking household -1.2(-1.7 to -0.6)%,p<0.001; living in social housing -0.8%(-1.3 to -0.2)% p = 0.01, and entitlement to free school meals -0.8%(-1.5 to -0.1)%,p<0.001. Social adversity and ethnicity, but not asthma, are associated with poorer performance in national school examinations. Policies to improve educational attainment in socially deprived areas should focus on these factors.

BackgroundParental weight status is a recognised predictor of offspring weight, however little is known about the influence of weight status of adult household members who may not be biologically related. We hypothesised that children sharing a household with at least one adult with excess weight would be more likely to live with overweight or obesity than those sharing a household with adults of healthy weight.MethodsWe linked 66,106 (98.5%) 5-year-old National Child Measurement Programme participants (2013–18) in North East London to their primary care records using pseudonymised NHS numbers, and linked household members using pseudonymised Unique Property Reference Numbers. The primary outcome was child excess weight (UK1990 clinical standards: overweight≥91st; obese≥98th centiles). Main explanatory variable: household weight status (obese:≥1adult BMI≥30 kg/m2; overweight:≥1adult 30 kg/m2>BMI≥25 kg/m2; healthy: all adults BMI<25 kg/m2). We used multivariable ordinal regression to estimate the adjusted odds [aOR] and 95% confidence intervals [CI] of child excess weight when living in overweight or obese adult households, after adjusting for child sex and ethnic group, household composition, and area-level deprivation. We conducted sensitivity analyses stratifying households by number of adults with available weight measurement. Analyses were conducted in R.ResultsRespectively 4,279 (10.4%) and 3,476 (8.5%) of 41,092 children with available household data were living with overweight or obesity. 13,091 (31.9%) children lived in overweight and 21,080 (51.3%) in obese households. Children living in overweight or obese households were more likely to be in a higher weight category (aOR 1.57 [1.43–1.72] and 2.82 [2.58–3.08] respectively), as were those from South Asian ethnic groups or living in single adult households (1.62 [1.52–1.72], and 1.33; [1.23–1.44] respectively). Children from Black ethnic groups (0.38 [0.34–0.42]) and multigenerational households (0.87; [0.80–0.94]) were less likely to be in a higher weight category. Associations attenuated and increased respectively for the subsamples of households with only one or more than one adult with available weight measurement.ConclusionYoung children live in varied non-nuclear households with shared health and dietary behaviours influenced by caregivers who are not always biologically related. In this ethnically diverse and disadvantaged population with high levels of child and adult obesity, we found strong associations with household-level adult weight status, and composition. Strengths include novel data linkages. Weights were not available for all adult household members. Further research is needed to understand mediators of these associations and the potential of adult-only interventions to support weight management in young children living with severe obesity.

There is increasing evidence that official population statistics are inaccurate at the local authority level, the fundamental administrative unit of the UK. The main source of official population statistics in the UK comes from the decennial census, last undertaken in 2011. The methodology and results of official population counts have been criticised and described as unfit for purpose. The three main purposes of population statistics are resource allocation, population ratios, and local planning and intelligence. Administrative data are data that is routinely collected for administrative purposes by organisations, government departments or companies and not for statistical or research purposes. This is in contrast with surveys which are designed and carried out as a specific information gathering exercise. This thesis describes a methodology for linking routinely collected administrative data for counting and profiling populations and other purposes at the local level. The benefits of this methodology are that it produces results more quickly than the decennial census, in a format that is more suitable for accurate and detailed analyses. Utilising existing datasets in this way reduces costs and adds value. The need and the evolution of this innovative methodology are set out, and the success and impact it has had are discussed, including how it has helped shape thinking on statistics in the UK. This research preceded the current paradigm shift in the UK for research and national statistics to move towards the use of linked administrative data. Future censuses after 2021 may no longer be in the traditional survey format, and the Office for National Statistics are exploring using a similar administrative data method at the national level as an alternative. The research in this thesis has been part of this inevitable evolution and has helped pave the way for this.