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OBJECTIVE:To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers. METHODS:Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007-16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007-16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment. RESULTS:Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035). CONCLUSIONS:Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.

Introduction: Features of built environment have been related to behavior modification and might stimulate cognitive activity with a potential impact on cognitive health in later life. The aim of this study is to investigate cross-sectional associations between features of land use, cognitive impairment and dementia and also explore urban and rural differences in these associations. Methods: Postcodes of the 7505 community-based participants (age 65+) in the Cognitive Function and Ageing Study II (collected in 2008–2011) were linked to environmental data from government statistics. A multilevel logistic regression was used to investigate associations between cognitive impairment (defined as MMSE≤25), dementia (GMS-AGECAT organicity level≥3) and land use features, including natural environment availability and land use mix, fitting interaction terms with three rural/urban categories. Data were analyzed in 2015. Results: Associations between features of land use and cognitive impairment were not linear. After adjusting for individual-level factors and area deprivation, living in areas with high land use mix was associated with a nearly 30% decreased odds of cognitive impairment (OR: 0.72; 95%CI: 0.58, 0.89). This was similar, yet non-significant, for dementia (OR: 0.70; 95%CI: 0.46, 1.06). In urban conurbations, living in areas with high natural environment availability was associated with 30% reduced odds of cognitive impairment (OR: 0.70; 95%CI: 0.50, 0.97). Conclusions: Non-linear associations between features of land use and cognitive impairment were confirmed in this new cohort of older people in England. Both a lack and overload of environmental stimulation may be detrimental to cognition in later life.

Introduction: Built environment features have been related to behavior modification and might stimulate cognitive activity with a potential impact on cognitive health in later life. This study investigated cross-sectional associations between features of land use and cognitive impairment and dementia, and also explored urban and rural differences in these associations. Methods: Postcodes of the 7,505 community-based participants (aged ≥65 years) in the Cognitive Function and Ageing Study II (collected in 2008-2011) were linked to environmental data from government statistics. Multilevel logistic regression investigated associations between cognitive impairment (defined as Mini-Mental State Examination score ≤25) and dementia (Geriatric Mental Status and Automatic Geriatric Examination for Computer-Assisted Taxonomy organicity level ≥3) and land use features, including natural environment availability and land use mix, fitting interaction terms with three rural/urban categories. Data were analyzed in 2015. Results: Associations between features of land use and cognitive impairment were not linear. After adjusting for individual-level factors and area deprivation, living in areas with high land use mix was associated with a nearly 30% decreased odds of cognitive impairment (OR=0.72, 95% CI=0.58, 0.89). This was similar, yet non-significant, for dementia (OR=0.70, 95% CI=0.46, 1.06). In conurbations, living in areas with high natural environment availability was associated with 30% reduced odds of cognitive impairment (OR=0.70, 95% CI=0.50, 0.97). Conclusions: Non-linear associations between features of land use and cognitive impairment were confirmed in this new cohort of older people in England. Both lack of and overload of environmental stimulation may be detrimental to cognition in later life.

OBJECTIVES: To explore the hypothesis that higher exposure to natural environments in local areas is associated with a lower odds of depression and anxiety in later life. DESIGN: A cross-sectional study based on the year-10 interview of the Medical Research Council Cognitive Function and Ageing Study (CFAS), a population-based study of ageing in the UK. Postcodes of the CFAS participants were mapped onto small geographic units, lower-layer super output areas (LSOAs) and linked to environmental data from government databases. The natural environment was characterised as the percentage of green space and private gardens in each LSOA based on the UK Generalised Land Use 2001 Dataset. PARTICIPANTS: 2424 people aged 74 and over in the CFAS year-10 follow-up interview (2001) from 4 English centres (Cambridgeshire, Nottingham, Newcastle and Oxford). MAIN OUTCOME MEASURES: Depression and anxiety; clinical and subthreshold cases were identified using the Geriatric Mental State Examination (GMS) package and its associated diagnostic algorithm: the Automated Geriatric Examination for Computer Assisted Taxonomy. RESULTS: Compared with the lowest quartile, living in the highest quartile of neighbourhood natural environment provision was associated with a reduced odds of subthreshold depression (OR 0.66, 95% CI 0.46 to 0.95), anxiety symptoms (OR 0.62, 95% CI 0.46 to 0.83) and their co-occurrence (OR 0.55, 95% CI 0.35 to 0.84) after adjusting for individual-level factors. Controlling for area deprivation attenuated the strength of associations for subthreshold depression by 20% but not for anxiety symptoms or for co-occurrence of the conditions. CONCLUSIONS: A high exposure to natural environments (green space and gardens) in communities was associated with fewer mental disorders among older people. Increasing provision of green environments in local areas could be a potential population-level intervention to improve mental health among older people. ; The Cognitive Function and Ageing Studies (CFAS) were funded by the Department of Health and the Medical Research Council [grant number G9901400]. Yu-Tzu Wu received a PhD scholarship from the Cambridge Trust, University of Cambridge. Fiona E. Matthews and A. Matthew Prina were supported by the Medical Research Council [grant number U105292687 and MR/K021907/1]. ; This is the final version of the article. It first appeared from BMJ via http://dx.doi.org/10.1136/bmjopen-2015-007936

OBJECTIVES: To explore the hypothesis that higher exposure to natural environments in local areas is associated with a lower odds of depression and anxiety in later life. DESIGN: A cross-sectional study based on the year-10 interview of the Medical Research Council Cognitive Function and Ageing Study (CFAS), a population-based study of ageing in the UK. Postcodes of the CFAS participants were mapped onto small geographic units, lower-layer super output areas (LSOAs) and linked to environmental data from government databases. The natural environment was characterised as the percentage of green space and private gardens in each LSOA based on the UK Generalised Land Use 2001 Dataset. PARTICIPANTS: 2424 people aged 74 and over in the CFAS year-10 follow-up interview (2001) from 4 English centres (Cambridgeshire, Nottingham, Newcastle and Oxford). MAIN OUTCOME MEASURES: Depression and anxiety; clinical and subthreshold cases were identified using the Geriatric Mental State Examination (GMS) package and its associated diagnostic algorithm: the Automated Geriatric Examination for Computer Assisted Taxonomy. RESULTS: Compared with the lowest quartile, living in the highest quartile of neighbourhood natural environment provision was associated with a reduced odds of subthreshold depression (OR 0.66, 95% CI 0.46 to 0.95), anxiety symptoms (OR 0.62, 95% CI 0.46 to 0.83) and their co-occurrence (OR 0.55, 95% CI 0.35 to 0.84) after adjusting for individual-level factors. Controlling for area deprivation attenuated the strength of associations for subthreshold depression by 20% but not for anxiety symptoms or for co-occurrence of the conditions. CONCLUSIONS: A high exposure to natural environments (green space and gardens) in communities was associated with fewer mental disorders among older people. Increasing provision of green environments in local areas could be a potential population-level intervention to improve mental health among older people.

Objective: Patterns of capability loss and disability onset among older people were investigated prospectively. Background: With aging, the gap between personal capability and environmental demand becomes wider, resulting in higher levels of disability in daily activities. Methods: Data from a longitudinal, population-based study were obtained for analysis, which recruited a representative sample of 13,004 people aged 65 years and older from five sites in Great Britain. Participants completed a baseline interview during 1990 to 1994 and follow-up interviews after 1, 2, 3, 6, 8, and 10 years. Those who reported full vision, hearing, thinking, locomotion, reaching, and dexterity ability as well as no disability in cooking, housework, shopping, and transportation at baseline were included in a survival analysis. Results: Locomotion was the first ability to be lost, followed by reaching, thinking, hearing, vision, and dexterity. Age at onset of disability was earliest for shopping, then housework, transportation, and cooking. Women were consistently younger at capability loss and disability onset than men except in terms of hearing and cooking. Conclusion: These findings suggest that capabilities required for product and service interaction follow a hierarchical pattern of loss, which has practical implications for design. Although interventions to reduce disability in the older population are likely to require changes that address more than one demand, capabilities lost early in old age should take precedence over those lost later. Application: A potential application of this research is in the development of an overall design strategy to enhance older people's ability to live independently.

Background: There have been fundamental shifts in the attitude towards, access to and nature of long term care in high income countries. The proportion and profile of the older population living in such settings varies according to social, cultural, and economic characteristics as well as governmental policies. Changes in the profiles of people in different settings are important for policy makers and care providers. Although details will differ, how change occurs across time is important to all, including lower and middle income countries developing policies themselves. Here change is examined across two decades in England. Methods and Findings: Using the two Cognitive Function and Ageing Studies (CFAS I: 77% response, CFAS II: 56% response), two population based studies of older people carried out in the same areas conducted two decades apart, the study diagnosis of dementia using the Automated Geriatric Examination for Computer Assisted Taxonomy, health and wellbeing were examined, focusing on long term care. The proportion of individuals with three or more health conditions increased for everyone living in long term care between CFAS I (47.6%, 95% CI: 42.3–53.1) and CFAS II (62.7%, 95% CI: 54.8–70.0) and was consistently higher in those without dementia compared to those with dementia in both studies. Functional impairment measured by activities of daily living increased in assisted living facilities from 48% (95% CI: 44%-52%) to 67% (95% CI: 62%-71%). Conclusions: Health profiles of residents in long term care have changed dramatically over time. Dementia prevalence and reporting multiple health conditions have increased. Receiving care in the community puts pressure on unpaid carers and formal services; these results have implications for policies about supporting people at home as well as for service provision within long term care including quality of care, health management, cost, and the development of a skilled, caring, and informed workforce.

Importance The global prevalence of autism spectrum disorder (ASD) has been reported to be between 1% and 2% of the population, with little research in Black, Asian, and other racial/ethnic minority groups. Accurate estimates of ASD prevalence are vital to planning diagnostic, educational, health, and social care services and may detect possible access barriers to diagnostic pathways and services and inequalities based on social determinants of health. Objective To evaluate whether socioeconomic disadvantage is associated with ASD prevalence and the likelihood of accessing ASD services in racial/ethnic minority and disadvantaged groups in England. Design, Setting, and Participants This case-control prevalence cohort study used the Spring School Census 2017 from the Pupil Level Annual Schools Census of the National Pupil Database, which is a total population sample that includes all English children, adolescents, and young adults aged 2 to 21 years in state-funded education. Data were collected on January 17, 2017, and analyzed from August 2, 2018, to January 28, 2020. Exposures Age and sex were treated as a priori confounders while assessing correlates of ASD status according to (1) race/ethnicity, (2) social disadvantage, (3) first language spoken, (4) Education, Health and Care Plan or ASD Special Educational Needs and Disability support status, and (5) mediation analysis to assess how social disadvantage and language might affect ASD status. Main Outcomes and Measures Sex- and age-standardized ASD prevalence by race/ethnicity and 326 English local authority districts in pupils aged 5 to 19 years. Results The final population sample consisted of 7 047 238 pupils (50.99% male; mean [SD] age, 10.18 [3.47] years) and included 119 821 pupils with ASD, of whom 21 660 also had learning difficulties (18.08%). The standardized prevalence of ASD was 1.76% (95% CI, 1.75%-1.77%), with male pupils showing a prevalence of 2.81% (95% CI, 2.79%-2.83%) and female pupils a prevalence of 0.65% (95% CI, 0.64%-0.66%), for a male-to-female ratio (MFR) of 4.32:1. Standardized prevalence was highest in Black pupils (2.11% [95% CI, 2.06%-2.16%]; MFR, 4.68:1) and lowest in Roma/Irish Travelers (0.85% [95% CI, 0.67%-1.03%]; MFR, 2.84:1). Pupils with ASD were more likely to face social disadvantage (adjusted prevalence ratio, 1.61; 95% CI, 1.59-1.63) and to speak English as an additional language (adjusted prevalence ratio, 0.64; 95% CI, 0.63-0.65). The effect of race/ethnicity on ASD status was mediated mostly through social disadvantage, with Black pupils having the largest effect (standardized mediation coefficient, 0.018; P < .001) and 12.41% of indirect effects through this way. Conclusions and Relevance These findings suggest that significant differences in ASD prevalence exist across racial/ethnic groups and geographic areas and local authority districts, indicating possible differential phenotypic prevalence or differences in detection or referral for racial/ethnic minority groups. ; ARU received funding from the Gillings Fellowship in Global Public Health and Autism Research, Grant Award YOG054 to the Cambridge Institute of Public Health (PI Carol Brayne). SBC received funding from Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 777394. The JU receives support from the European Union's Horizon 2020 research and innovation programme and EFPIA and AUTISM SPEAKS, Autistica, SFARI. SBC also received funding from the Autism Research Trust, Autistica, the MRC, the Wellcome Trust and the NIHR Cambridge Biomedical Research Centre. The research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East of England at Cambridgeshire and Peterborough NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, NIHR or Department of Health and Social Care.

This study was funded by the Gillings Fellowship in Global Public Health and Autism Research (Grant Award YOG054) and the Innovative Medicines Initiative 2 Joint Undertaking (grant agreement No. 777394). ; The Soviet occupation of the Baltic States followed by joining the United Nations (UN) and European Union make these countries an interesting point of comparison in the development of autism and education policy. This study investigates how policies changed following the transition and how the right and access to education are facilitated for autistic children by performing a path dependence analysis. All Baltic States created new education policies following the transition out of the Soviet era, with their accession to the UN and their appetite to follow internationally available guidance. The right to education for all children in was adopted in all education systems. Education facilities for children with disabilities were implemented in all countries. Afterward, all countries started toward the development of more inclusive systems. Nevertheless, the majority of policies did not specify for autism, yet covered special education needs in general. A development in Latvia should be noted, where various special education needs are outlined in national policy, along with provisions and professional assistance required to address them in mainstream or special classrooms. Ultimately, education policy flourished after the transition. Their development caught up to other European Union countries and they are currently working on implementing inclusive education.

Dementia is receiving increasing attention from governments and politicians. Epidemiological research based on western European populations done 20 years ago provided key initial evidence for dementia policy making, but these estimates are now out of date because of changes in life expectancy, living conditions, and health profiles. To assess whether dementia occurrence has changed during the past 20-30 years, investigators of five different studies done in western Europe (Sweden [Stockholm and Gothenburg], the Netherlands [Rotterdam], the UK [England], and Spain [Zaragoza]) have compared dementia occurrence using consistent research methods between two timepoints in well-defined geographical areas. Findings from four of the five studies showed non-significant changes in overall dementia occurrence. The only significant reduction in overall prevalence was found in the study done in the UK, powered and designed explicitly from its outset to detect change across generations (decrease in prevalence of 22%; p=0.003). Findings from the study done in Zaragoza (Spain) showed a significant reduction in dementia prevalence in men (43%; p=0.0002). The studies estimating incidence done in Stockholm and Rotterdam reported non-significant reductions. Such reductions could be the outcomes from earlier population-level investments such as improved education and living conditions, and better prevention and treatment of vascular and chronic conditions. This evidence suggests that attention to optimum health early in life might benefit cognitive health late in life. Policy planning and future research should be balanced across primary (policies reducing risk and increasing cognitive reserve), secondary (early detection and screening), and tertiary (once dementia is present) prevention. Each has their place, but upstream primary prevention has the largest effect on reduction of later dementia occurrence and disability. ; Yu-Tzu Wu received a PhD scholarship from the Cambridge Trust, University of Cambridge. Fiona E. Matthews was supported by the Medical Research Council [grant number U105292687]. ; This is the author accepted manuscript. The final version is available from Elsevier via http://dx.doi.org/10.1016/S1474-4422(15)00092-7

Background: few studies have investigated the impact of the community environment, as distinct from area deprivation, on cognition in later life. This study explores cross-sectional associations between cognitive impairment and dementia and environmental features at the community level in older people. Method: the postcodes of the 2,424 participants in the year-10 interview of the Cognitive Function and Ageing Study in England were mapped into small area level geographical units (Lower-layer Super Output Areas) and linked to environmental data in government statistics. Multilevel logistic regression was conducted to investigate associations between cognitive impairment (defined as MMSE a parts per thousand currency sign 25), dementia (organicity level a parts per thousand yen3 in GMS-AGECAT) and community level measurements including area deprivation, natural environment, land use mix and crime. Sensitivity analyses tested the impact of people moving residence within the last two years. Results: higher levels of area deprivation and crime were not significantly associated with cognitive impairment and dementia after accounting for individual level factors. Living in areas with high land use mix was significantly associated with a nearly 60% reduced odds of dementia (OR: 0.4; 95% CI: 0.2, 0.8) after adjusting for individual level factors and area deprivation, but there was no linear trend for cognitive impairment. Increased odds of dementia (OR: 2.2, 95% CI: 1.2, 4.2) and cognitive impairment (OR: 1.4, 95% CI: 1.0, 2.0) were found in the highest quartile of natural environment availability. Findings were robust to exclusion of the recently relocated. Conclusion: features of land use have complex associations with cognitive impairment and dementia. Further investigations should focus on environmental influences on cognition to inform health and social policies.

Children with special education needs (SEN), such as children with autism, benefit from being included in education along with typical peers. However, development and implementation of inclusive education (IE) is considered difficult. This paper identifies conditions that facilitate IE development for children with autism in the European Union and benchmarks to track IE policy development. Education policy data from 30 legislative regions in the European Union were analyzed through a qualitative comparative analysis using eight conditions: a definition of SEN, the right to education for children with SEN, support for teaching staff, support services for children with SEN, individualized learning outcomes, parental involvement, and mixed mainstream classes. The right to education for children with SEN is implemented in all regions under study. Seven of the examined conditions were associated with IE: an established definition of SEN, support for teaching staff, support services for children with SEN, individualized learning outcomes, parental involvement, IE policies, and mixed mainstream classrooms. Mixed classrooms and support services for children with SEN were identified as necessary for IE. IE policies and support for teaching staff were present in all scenarios that facilitated IE. While the analysis was initially focused on autism, the policies consisted predominantly of general SEN policies, allowing the results to be interpreted in a wider context, beyond autism. Ultimately, mixed mainstream classrooms and support services for children with special needs were found essential for consistent IE development. Support for teaching staff and IE policies facilitate IE and should be further explored and implemented.

The results leading to this publication have received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 777394 for the project AIMS-2-TRIALS. This Joint Undertaking receives support from the European Union's Horizon 2020 research and innovation programme and EFPIA and AUTISM SPEAKS, Autistica, SFARI. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. Any views expressed are those of the author(s) and not necessarily those of the funders.

Abstract: This study explores how autism and education policy are affected by austerity measures in Ireland, Portugal, Italy, and Greece by using a path dependence analysis. The implementation of mixed mainstream classrooms and improvements to infrastructure coincided with the ratification of inclusive education policy. Austerity measures appeared temporally associated with furthering of integration and inclusion policy for all countries under study, potentially due to the economic incentives of an integrated system. This trend is especially visible in Ireland, Portugal, and Greece, whereas lesser so in Italy. Even though the initial focus of this analysis was autism, the findings are applicable to the general area of special education needs due to the non‐specific nature of national policies.