The Impact of the Social Determinants of Human Health on Companion Animal Welfare.

The social determinants of health (SDH) focus on the social, physical and economic factors that impact human health. Studies have revealed that animal guardians face a range of challenges in attaining positive welfare outcomes for their companion animals, which can be influenced by socioeconomic and environmental factors. Despite this, there is a lack of research specifically exploring the relationship between SDH and animal welfare outcomes. Given that the SDH impact on humans, which in turn directly impacts on their companion animal, it is important to adapt an SDH framework for companion animal welfare by characterising the impact of the SDH on companion animal guardians in their attempts to care for their animals and, by extension, the associated welfare outcomes. This paper explores how these human health determinants may impact animal welfare and the possible challenges that may arise for the guardian when attempting to meet their companion animal's welfare needs. By integrating the SDH with other key frameworks, including the five domains model of animal welfare, through multidisciplinary collaboration, this framework can be used to inform future programs aiming to improve animal welfare.

Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role.

PROBLEM: The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas. BACKGROUND: Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation. AIM: We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care. METHODS: An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups. FINDINGS: Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care. DISCUSSION: A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care. CONCLUSION: Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

Emulating a target trial of intensive nurse home visiting in the policy-relevant population using linked administrative data.

BACKGROUND: Populations willing to participate in randomized trials may not correspond well to policy-relevant target populations. Evidence of effectiveness that is complementary to randomized trials may be obtained by combining the 'target trial' causal inference framework with whole-of-population linked administrative data. METHODS: We demonstrate this approach in an evaluation of the South Australian Family Home Visiting Program, a nurse home visiting programme targeting socially disadvantaged families. Using de-identified data from 2004-10 in the ethics-approved Better Evidence Better Outcomes Linked Data (BEBOLD) platform, we characterized the policy-relevant population and emulated a trial evaluating effects on child developmental vulnerability at 5 years (n = 4160) and academic achievement at 9 years (n = 6370). Linkage to seven health, welfare and education data sources allowed adjustment for 29 confounders using Targeted Maximum Likelihood Estimation (TMLE) with SuperLearner. Sensitivity analyses assessed robustness to analytical choices. RESULTS: We demonstrated how the target trial framework may be used with linked administrative data to generate evidence for an intervention as it is delivered in practice in the community in the policy-relevant target population, and considering effects on outcomes years down the track. The target trial lens also aided in understanding and limiting the increased measurement, confounding and selection bias risks arising with such data. Substantively, we did not find robust evidence of a meaningful beneficial intervention effect. CONCLUSIONS: This approach could be a valuable avenue for generating high-quality, policy-relevant evidence that is complementary to trials, particularly when the target populations are multiply disadvantaged and less likely to participate in trials.

The Hospital Burden Associated With Intergenerational Contact With the Welfare System in Australia.

Importance: Intergenerational welfare contact is a policy issue because of the personal and social costs of entrenched disadvantage; yet, few studies have quantified the burden associated with intergenerational welfare contact for health. Objective: To examine the proportion of individuals who experienced intergenerational welfare contact and other welfare contact types and to estimate their cause-specific hospital burden. Design, Setting, and Participants: This cohort study used a whole-of-population linked administrative dataset of individuals followed from birth to age 20 years using deidentified data from the Better Evidence Better Outcomes Linked Data platform (Australian Government Centrelink [welfare payments], birth registration, perinatal birth records, and inpatient hospitalizations). Participants included individuals born in South Australia from 1991 to 1995 and their parents. Analysis was undertaken from January 2020 to June 2022. Exposures: Using Australian Government Centrelink data, welfare contact was defined as 1 or more parents receiving a means-tested welfare payment (low-income, unemployment, disability, or caring) when children were aged 11 to 15 years, or youth receiving payment at ages 16 to 20 years. Intergenerational welfare contact was defined as welfare contact occurring in both parent and offspring generations. Offspring were classified as: no welfare contact, parent-only welfare contact, offspring-only welfare contact, or intergenerational welfare contact. Main Outcomes and Measures: Hospitalization rates and cumulative incidence were estimated by age, hospitalization cause, and welfare contact group. Results: A total of 94 358 offspring (48 589 [51.5%] male) and 143 814 parents were included in analyses. The study population included 32 969 offspring (34.9%) who experienced intergenerational welfare contact. These individuals were more socioeconomically disadvantaged at birth and had the highest hospitalization rate (133.5 hospitalizations per 1000 person-years) compared with individuals with no welfare contact (46.1 hospitalizations per 1000 person-years), individuals with parent-only welfare contact (75.0 hospitalizations per 1000 person-years), and individuals with offspring-only welfare contact (87.6 hospitalizations per 1000 person-years). Hospitalizations were frequently related to injury, mental health, and pregnancy. For example, the proportion of individuals with intergenerational welfare contact who had experienced at least 1 hospitalization at ages 16 to 20 years was highest for injury (9.0% [95% CI, 8.7%-9.3%]). Conclusions and Relevance: In this population-based cohort study, individuals who experienced intergenerational welfare contact represented one-third of the population aged 11 to 20 years. Compared with individuals with parent-only welfare contact, individuals with intergenerational welfare contact were more disadvantaged at birth and had 78% higher hospitalization rates from age 11 to 20 years, accounting for more than half of all hospitalizations. Frequent hospitalization causes were injuries, mental health, and pregnancy. This study provides the policy-relevant estimate for what it could mean to break cycles of disadvantage for reducing hospital burden.

Modelling the potential for parenting skills interventions to reduce inequalities and population prevalence of children's mental health problems: Evidence from the Millennium Cohort Study.

Parenting programmes can improve parenting quality and, in turn, children's mental health. If scaled-up, they have the potential to reduce population inequalities and prevalence in child mental health problems (MHP). However, this cannot be investigated with trials. Using data from the UK Millennium Cohort Study (18,000 children born 2000-2002), we simulated population impact of scale-up of seven parenting programmes. Predicted probabilities of child MHP (Strengths and Difficulties Questionnaire) by household income quintile (Risk ratios [RRs] and differences [RDs], 95% confidence intervals [CI]) were estimated from logistic marginal structural models, adjusting for parenting quality scores (Child-Parent Relationship Scale at 3 years) and confounders. The impact of scaling-up parenting programmes was simulated by re-estimating predicted probabilities of child MHP after increasing parenting scores according to intervention intensity, targeting mechanisms and programme uptake levels. Analyses included data from 14,399 children, with survey weights and multiple imputation addressing sampling design, attrition and item missingness. Prevalence of child MHP at 5 years was 11.3% (11.4% unadjusted), with relative and absolute income inequalities (RR = 4.8[95%CI:3.6-5.9]; RD = 15.8%[13.4-18.2]). In simulations, universal, non-intensive parenting programmes reduced prevalence (9.4%) and absolute inequalities (RR = 5.0[95%CI:3.8-6.2]; RD = 13.6%[11.5-15.7]). Intensive programmes, targeting a range of potential risk criteria (e.g. receipt of means-tested benefits), reduced inequalities (RR = 4.0[95%CI:3.0-4.9]; RD = 12.4%[10.3-14.6] and, to a lesser extent, prevalence (10.3%). By simulating implementation of parenting programmes, we show that universal non-intensive and targeted intensive approaches have the potential to reduce child MHP at population level, and to reduce but not eliminate inequalities, with important implications for future policy and practice.

Characteristics of paediatric frequent presenters at emergency departments: A whole-of-population study.

AIM: To quantify the frequency of emergency department (ED) presentations and profile the socio-demographic, health and presentation characteristics of paediatric ED frequent presenters. METHODS: A population-based data linkage study of 55 921 children in the South Australian Early Childhood Data Project aged 0-12 years with 100 976 presentations to public hospital EDs in South Australia. For each child, the total number of recurrent ED presentations during a 364-day period post-index presentation was calculated. Frequent presenters were children who experienced ≥4 recurrent ED presentations. We determined the socio-demographic, health and presentation characteristics by number of recurrent presentations. RESULTS: Children with ≥4 recurrent presentations (4.4%) accounted for 15.4% of all paediatric ED presentations and 22.5% of subsequent admissions to hospital during the 12-month study period. Compared to children with no recurrent ED presentation, frequent presenters had higher proportions of socio-economic and health disadvantage at birth. One in two (49.3%) frequent presenters had at least one injury presentation and one (21.3%) in five had at least one presentation related to a chronic condition. CONCLUSIONS: Children with ≥4 presentations do not represent the majority of ED users. Nevertheless, they represent a disproportionate burden accounting for 15% of all paediatric ED presentations in a 12-month period. Frequent presenters were characterised by early socio-economic and health disadvantage, and childhood injury. Strategies targeting social disadvantage and childhood injury may reduce the burden of ED presentations.

Incidence of type 1 diabetes by socio-demographic characteristics among South Australian children: Whole-of-population study.

AIM: To describe and compare the incidence of type 1 diabetes (T1D) in South Australia by individual and area-level socio-economic characteristics among children aged ≤11 years. METHODS: This is a whole-of-population, data linkage study (n = 231 685) conducted in South Australia, and included children born from 2002 to 2013, hospitalisation followed from 2002 to 2014. The study used de-identified, linked administrative hospitalisation, birth and perinatal data from the South Australian Early Childhood Data Project. Incidence was calculated by identifying T1D cases from T1D-related hospitalisations using International Classification of Disease, 10th Revision, Australian Modification diagnosis codes (E10, E101-E109). RESULTS: Overall, 333 children aged ≤11 years (173 boys) were identified as having T1D. The T1D incidence rate was 23.0 per 100 000 person-years (95% confidence interval (CI): 20.7-25.7), with no sex difference. T1D incidence was higher among children whose mothers were Caucasian, private patients and whose parents were employed. For example, T1D incidence was 26.0 per 100 000 (95% CI: 22.8-29.5) among children with both parents employed, compared to 20.0 per 100 000 (95% CI: 12.3-30.6) among children with both parents unemployed. There was no clear gradient in the association between area-level socio-economic position and T1D, with highest incidence for the fourth quintile (26.5 per 100 000 (95% CI: 20.9-33.1)). The most advantaged area (19.4 per 100 000 (95% CI: 13.8-26.5)) had lower incidence than the most disadvantaged area (23.5 per 100 000 (95% CI: 18.9-28.9)). CONCLUSION: T1D incidence rates differed depending on the measures of socio-economic characteristics. Individual-level indicators showed higher incidence among more advantaged children; however, there was no clear area-level socio-economic patterning of T1D.

Educational outcomes among children with type 1 diabetes: Whole-of-population linked-data study.

BACKGROUND: Challenges with type 1 diabetes (T1D) blood glucose management and illness-related school absences potentially influence children's educational outcomes. However, evidence about the impact of T1D on children's education is mixed. The objectives were to estimate the effects of T1D on children's educational outcomes, and compare time since T1D diagnosis (recent diagnosis [≤2 years] and 3 to 10 years long exposure) on educational outcomes. METHODS: This whole-of-population study used de-identified, administrative linked-data from the South Australian Early Childhood Data Project. T1D was identified from hospital ICD-10-AM diagnosis codes (E10, ranging E101 to E109), from 2001 to 2014. Educational outcomes were measured in grade 5 by the National Assessment Program-Literacy and Numeracy (NAPLAN, 2008-2015) for children born from 1999 to 2005. Analyses were conducted using augmented inverse probability of treatment weighting. Multiple imputations was used to impute missing data. RESULTS: Among 61 445 children born in South Australia who had undertaken NAPLAN assessments, 162 had T1D. There were negligible differences in the educational outcomes of children with and without T1D, and between recently diagnosed and those with longer exposure. For example, the mean reading score was 482.8 ± 78.9 for children with T1D and 475.5 ± 74.3 for other children. The average treatment effect of 6.8 (95% CI - 6.3-19.9) reflected one-tenth of a SD difference in the mean reading score of children with and without T1D. CONCLUSION: Children with T1D performed similarly on literacy and numeracy in grade 5 (age ~ 10-years) compared to children without T1D. This could be due to effective T1D management.

Associations of adverse childhood experiences with educational attainment and adolescent health and the role of family and socioeconomic factors: A prospective cohort study in the UK.

BACKGROUND: Experiencing multiple adverse childhood experiences (ACEs) is a risk factor for many adverse outcomes. We explore associations of ACEs with educational attainment and adolescent health and the role of family and socioeconomic factors in these associations. METHODS AND FINDINGS: Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective cohort of children born in southwest England in 1991-1992, we assess associations of ACEs between birth and 16 years (sexual, physical, or emotional abuse; emotional neglect; parental substance abuse; parental mental illness or suicide attempt; violence between parents; parental separation; bullying; and parental criminal conviction, with data collected on multiple occasions between birth and age 16) with educational attainment at 16 years (n = 9,959) and health at age 17 years (depression, obesity, harmful alcohol use, smoking, and illicit drug use; n = 4,917). We explore the extent to which associations are robust to adjustment for family and socioeconomic factors (home ownership, mother and partner's highest educational qualification, household social class, parity, child's ethnicity, mother's age, mother's marital status, mother's depression score at 18 and 32 weeks gestation, and mother's partner's depression score at 18 weeks gestation) and whether associations differ according to socioeconomic factors, and we estimate the proportion of adverse educational and health outcomes attributable to ACEs or family or socioeconomic measures. Among the 9,959 participants (49.5% female) included in analysis of educational outcomes, 84% reported at least one ACE, 24% reported 4 or more ACEs, and 54.5% received 5 or more General Certificates of Secondary Education (GCSEs) at grade C or above, including English and Maths. Among the 4,917 participants (50.1% female) included in analysis of health outcomes, 7.3% were obese, 8.7% had depression, 19.5% reported smoking, 16.1% reported drug use, and 10.9% reported harmful alcohol use. There were associations of ACEs with lower educational attainment and higher risk of depression, drug use, and smoking. For example, odds ratios (ORs) for 4+ ACEs compared with no ACEs after adjustment for confounders were depression, 2.4 (1.6-3.8, p < 0.001); drug use, 3.1 (2.1-4.4, p < 0.001); and smoking, 2.3 (1.7-3.1, p < 0.001). Associations with educational attainment attenuated after adjustment but remained strong; for example, the OR after adjustment for confounders for low educational attainment comparing 4+ ACEs with no ACEs was 2.0 (1.7-2.4, p < 0.001). Associations with depression, drug use, and smoking were not altered by adjustment. Associations of ACEs with harmful alcohol use and obesity were weak. For example, ORs for 4+ ACEs compared with no ACEs after adjustment for confounders were harmful alcohol use, 1.4 (0.9-2.0, p = 0.10) and obesity, 1.4 (0.9-2.2, p = 0.13) We found no evidence that socioeconomic factors modified the associations of ACEs with educational or health outcomes. Population attributable fractions (PAFs) for the adverse educational and health outcomes range from 5%-15% for 4+ ACEs and 1%-19% for low maternal education. Using data from multiple questionnaires across a long period of time enabled us to capture a detailed picture of the cohort members' experience of ACEs; however, a limitation of our study is that this resulted in a high proportion of missing data, and our analyses assume data are missing at random. CONCLUSIONS: This study demonstrates associations between ACEs and lower educational attainment and higher risks of depression, drug use, and smoking that remain after adjustment for family and socioeconomic factors. The low PAFs for both ACEs and socioeconomic factors imply that interventions that focus solely on ACEs or solely on socioeconomic deprivation, whilst beneficial, would miss most cases of adverse educational and health outcomes. This interpretation suggests that intervention strategies should target a wide range of relevant factors, including ACEs, socioeconomic deprivation, parental substance use, and mental health.

Effect of maternal smoking during pregnancy on childhood type 1 diabetes: a whole-of-population study.

AIMS/HYPOTHESIS: Evidence of an association between maternal smoking during pregnancy (prenatal smoking) and childhood type 1 diabetes is mixed. Previous studies have been small and potentially biased due to unmeasured confounding. The objectives of this study were to estimate the association between prenatal smoking and childhood type 1 diabetes, assess residual confounding with a negative control design and an E-value analysis, and summarise published effect estimates from a meta-analysis. METHODS: This whole-of-population study (births from 1999 to 2013, participants aged ≤15 years) used de-identified linked administrative data from the South Australian Early Childhood Data Project. Type 1 diabetes was diagnosed in 557 children (ICD, tenth edition, Australian Modification [ICD-10-AM] codes: E10, E101-E109) during hospitalisation (2001-2014). Families not given financial assistance for school fees was a negative control outcome. Adjusted Cox proportional HRs were calculated. Analyses were conducted on complete-case (n = 264,542, type 1 diabetes = 442) and imputed (n = 286,058, type 1 diabetes = 557) data. A random-effects meta-analysis was used to summarise the effects of prenatal smoking on type 1 diabetes. RESULTS: Compared with non-smokers, children exposed to maternal smoking only in the first or second half of pregnancy had a 6% higher type 1 diabetes incidence (adjusted HR 1.06 [95% CI 0.73, 1.55]). Type 1 diabetes incidence was 24% lower (adjusted HR 0.76 [95% CI 0.58, 0.99]) among children exposed to consistent prenatal smoking, and 16% lower for exposure to any maternal smoking in pregnancy (adjusted HR 0.84 [95% CI 0.67, 1.08]), compared with the unexposed group. Meta-analytic estimates showed 28-29% lower risk of type 1 diabetes among children exposed to prenatal smoking compared with those not exposed. The negative control outcome analysis indicated residual confounding in the prenatal smoking and type 1 diabetes association. E-value analysis indicated that unmeasured confounding associated with prenatal smoking and childhood type 1 diabetes, with a HR of 1.67, could negate the observed effect. CONCLUSIONS/INTERPRETATION: Our best estimate from the study is that maternal smoking in pregnancy was associated with 16% lower childhood type 1 diabetes incidence, and some of this effect was due to residual confounding.

Could Greater Physical Activity Reduce Population Prevalence and Socioeconomic Inequalities in Children's Mental Health Problems? A Policy Simulation.

BACKGROUND: One in four children 5-16 years (y) of age shows signs of mental health problems in the United Kingdom; risk is higher in economically disadvantaged groups. Greater physical activity is associated with lower risk of internalizing problems such as depression and anxiety. We simulated the potential impact of population-wide physical activity interventions on overall prevalence of internalizing problems, and by family income. Interventions were based on the World Health Organization (WHO) children's target of 60 minutes (min) of moderate-to-vigorous physical activity per day and trial evidence. METHODS: Data were from the UK Millennium Cohort Study, a population-representative cohort of children born in 2000-2002. Household income (5 y) was the exposure; internalizing problems (outcome) were measured using the Strengths and Difficulties Questionnaire (11 y). Of 18,296 singletons, 6,497 had accelerometer physical activity data (mediator, manipulated to simulate interventions) at 7 y. We predicted probabilities of outcome according to exposure in marginal structural models, weighted for attrition and confounding, and adjusted for observed mediator. We then re-estimated probabilities in different physical activity intervention scenarios, assessing income inequalities in internalizing problems with risk ratios (RRs) and differences (RDs) according to income quintile. RESULTS: Simulating universal achievement of the WHO target led to little change in prevalence (10% [95% CI = 8%, 12%]) and socioeconomic inequalities in internalizing problems; RR: 2.2 (1.1, 3.4); RD: 8% [5%,13%]). More modest increases in physical activity achieved weaker results. CONCLUSIONS: Our simulations suggest that large increases in moderate-to-vigorous physical activity in the United Kingdom would have little effect on prevalence and inequalities in child mental health problems.

Potentially preventable hospitalisations in children: a comparison of definitions.

OBJECTIVE: To compare admission rate, cumulative incidence and social distribution of potentially preventable hospitalisations (PPHs) among children according to the current Australian adult definition, and the child definition developed in New Zealand. DESIGN, SETTING, PARTICIPANTS: Deidentified, linked public hospital, births registry and perinatal data of children aged 0-10 years born 2002-2012 in South Australia (n=1 91 742). MAIN OUTCOME MEASURES: PPH admission rates among 0-10 year olds and cumulative incidence by age 5 under the adult and child definitions. Cumulative incidence was assessed across indicators of social and health disadvantage. RESULTS: PPH admission rates among 0-10 year olds were 25.6 (95% CI 25.3 to 25.9) and 59.9 (95% CI 59.5 to 60.4) per 1000 person-years for the adult and child definitions, respectively. Greater absolute differences in admission rates between definitions were observed at younger ages (age <1 difference: 75.6 per 1000 person-years; age 10 difference: 1.4 per 1000 person-years). Cumulative incidence of PPHs among 0-5 year olds was higher under the child (25.0%, 95% CI 24.7 to 25.2) than the adult definition (12.8%, 95% CI 12.6 to 13.0). Higher PPH incidence was associated with social and health disadvantage. Approximately 80% of the difference in admission rate between definitions was due to five conditions. CONCLUSIONS: Respiratory conditions and gastroenteritis were key contributors to the higher PPH admission rate and cumulative incidence among children when calculated under the child definition compared to the adult definition. Irrespective of definition, higher PPH cumulative incidence was associated with social and health disadvantage at birth.

The controlled direct effect of temperament at 2-3 years on cognitive and academic outcomes at 6-7 years.

There is widespread interest in temperament and its impact upon cognitive and academic outcomes. Parents adjust their parenting according to their child's temperament, however, few studies have accounted for parenting while estimating the association between temperament and academic outcomes. We examined the associations between temperament (2-3 years) and cognitive and academic outcomes (6-7 years) when mediation by parenting practices (4-5 years) was held constant, by estimating the controlled direct effect. Participants were from the Longitudinal Study of Australian Children (n = 5107). Cognitive abilities were measured by the Peabody Picture Vocabulary Test (verbal) and the Matrix Reasoning test (non-verbal). Literacy and numeracy were reported by teachers using the Academic Rating Scale. Mothers reported children's temperament using the Short Temperament Scale for Toddlers (subscales: reactivity, approach, and persistence). Parenting practices included items about engagement in activities with children. Marginal structural models with inverse probability of treatment weights were used to estimate the controlled direct effect of temperament, when setting parenting to the mean. All temperament subscales were associated with cognitive abilities, with persistence showing the largest associations with verbal (PPVT; ß = 0.58; 95%CI 0.27, 0.89) and non-verbal (Matrix Reasoning: ß = 0.19; 0.02, 0.34) abilities. Higher persistence was associated with better literacy (ß = 0.08; 0.03, 0.13) and numeracy (ß = 0.08; 0.03, 0.13), and higher reactivity with lower literacy (ß = -0.08; -0.11, -0.05) and numeracy (ß = -0.07; -0.10, -0.04). There was little evidence that temperamental approach influenced literacy or numeracy. Overall, temperament had small associations with cognitive and academic outcomes after accounting for parenting and confounders.

Bullying and sexual abuse and their association with harmful behaviours, antidepressant use and health-related quality of life in adulthood: a population-based study in South Australia.

BACKGROUND: Few representative sample studies have reported estimates of bullying and sexual abuse in Australia. By using face-to-face interviews and self-labelling questions, we investigated the prevalence of these forms of abuse and their relationship with current harmful behaviours (smoking dependence, excessive alcohol intake, binge eating), antidepressant use, and the physical (PCS) and mental (MCS) components of health-related quality of life. METHODS: This study was a population-based survey that investigated 2873 South Australians in 2015 (48.8 ± 18.1 years; 49.3% males). Bullying and sexual abuse (age of onset and duration) and their outcomes were investigated through household interviews. Associations were adjusted for sociodemographic variables by using regression models. RESULTS: 45.6% (95% CI 43.3-47.9) of the participants were bullied, and 10.4% (95% CI 9.1-11.9) sexually abused; 7.3% (95% CI 6.2-8.5) reported experiencing both forms of abuse. Moreover, 15.8% of those bullied and 15.0% of those sexually abused suffered from these forms of abuse for > 24 months. Smoking dependence (7.8%) was twice as frequent among those who experienced bullying for > 24 months or when sexual abuse occurred in childhood (< 10 years) or adulthood (20+ years) or lasted ≥1 month. Excessive alcohol intake (14.3%) was more frequent when bullying occurred in childhood or lasted > 24 months. Binge eating (8.1%) was more frequent among those bullied or sexually abused in adulthood, but duration did not show a clear pattern. Antidepressant use was up to four times more likely, and PCS or MCS lower among those who were bullied or sexually abused, independent of when these forms of abuse started or their duration. The cumulative adverse relationship of bullying and sexual abuse with the investigated outcomes was more evident for smoking dependence, binge eating, PCS, and MCS than for antidepressant use, but no association was observed with alcohol intake. CONCLUSIONS: The use of self-labelling questions to investigate sensitive areas such as bullying and sexual abuse in a survey is feasible. Such questions provided estimates that are consistent with findings from studies using more detailed instruments. Bullying and sexual abuse have an additive adverse association with various outcomes. Identifying survivors of both forms of abuse is important to avoid more serious consequences.

Temporal effects of maternal psychological distress on child mental health problems at ages 3, 5, 7 and 11: analysis from the UK Millennium Cohort Study.

BACKGROUND: Psychological distress is common among women of childbearing age, and limited longitudinal research suggests prolonged exposure to maternal distress is linked to child mental health problems. Estimating effects of maternal distress over time is difficult due to potential influences of child mental health problems on maternal distress and time-varying confounding by family circumstances. METHODS: We analysed the UK Millennium Cohort Study, a nationally representative sample with data collected throughout childhood. Adopting a marginal structural modelling framework, we investigated effects of exposure to medium/high levels of maternal psychological distress (Kessler-6 score 8+) on child mental health problems (Strengths and Difficulties Questionnaire borderline/abnormal behaviour cut-off) using maternal and child mental health data at 3, 5, 7 and 11 years, accounting for the influence of child mental health on subsequent maternal distress, and baseline and time-varying confounding. RESULTS: Prior and concurrent exposures to maternal distress were associated with higher levels of child mental health problems at ages 3, 5, 7 and 11 years. For example, elevated risks of child mental health problems at 11 years were associated with exposure to maternal distress from 3 years [risk ratio (RR) 1.27 (95% confidence interval (CI) 1.08-1.49)] to 11 years [RR 2.15 (95% CI 1.89-2.45)]. Prolonged exposure to maternal distress at ages 3, 5, 7 and 11 resulted in an almost fivefold increased risk of child mental health problems. CONCLUSIONS: Prior, concurrent and, particularly, prolonged exposure to maternal distress raises risks for child mental health problems. Greater support for mothers experiencing distress is likely to benefit the mental health of their children.

What if all children achieved WHO recommendations on physical activity? Estimating the impact on socioeconomic inequalities in childhood overweight in the UK Millennium Cohort Study.

BACKGROUND: The World Health organization (WHO) recommends that children engage in 60 min daily moderate-to-vigorous physical activity (dMVPA). Just half of children in the UK achieve these levels (with similarly low levels in other high-income countries). Thus, the dMVPA target is a focus of national obesity strategies. However, the potential impact of increased physical activity on prevalence and inequalities in childhood overweight is unknown. Using objective data from the Millennium Cohort Study (∼18 000 children born 2000-02) we simulated a series of hypothetical physical activity intervention scenarios: achievement of the target, and more realistic increases demonstrated in trials. METHODS: Predicted probabilities of overweight and obesity (using measured heights and weights at age 11) were estimated in multinomial marginal structural models, adjusting for dMVPA (measured with accelerometers at age 7) and confounding. Inequalities were assessed according to household income quintiles [risk ratios (RRs) and risk differences (RDs)]. Intervention scenarios were simulated by re-estimating predicted probabilities of overweight/obesity after manipulating (increasing) dMVPA by varying amounts, for different eligibility criteria and with varying uptake. Analyses included 6493 children with accelerometer data. Survey weights and multiple imputation addressed sampling design, attrition and item missingness. RESULTS: In all, 27% children were overweight/obese, with relative and absolute inequalities in the expected direction; 51% children were achieving 60 min dMVPA, with those from the lowest income quintile achieving, on average, 3 min more dMVPA than those from the highest income quintile. A simulation of universal achievement of the dMVPA target reduced the prevalence of overweight/obesity to 22%, but increased relative inequalities (absolute inequalities were unchanged). Smaller increases in dMVPA (informed by intervention evidence) did little to reduce prevalence or inequalities, even when targeting high-risk groups. CONCLUSIONS: Universal achievement of the WHO dMVPA target, if attainable, would reduce prevalence of childhood overweight and obesity but not inequalities. Scale-up of more realistic interventions would have limited impact.

A systematic review and meta-analysis of effects of early life non-cognitive skills on academic, psychosocial, cognitive and health outcomes.

Success in school and the labour market relies on more than high intelligence. Associations between "non-cognitive" skills in childhood, such as attention, self-regulation, and perseverance, and later outcomes have been widely investigated. In a systematic review of this literature, we screened 9553 publications, reviewed 554 eligible publications, and interpreted results from 222 better quality publications. Better quality publications comprised randomised experimental and quasi-experimental studies (EQIs), and observational studies that made reasonable attempts to control confounding. For academic achievement outcomes there were 26 EQI publications but only 14 were available for meta-analysis with effects ranging from 0.16 to 0.37SD. However, within sub-domains effects were heterogeneous. The 95% prediction interval for literacy was consistent with negative, null and positive effects (-0.13 to 0.79). Similarly heterogeneous findings were observed for psychosocial, cognitive and language, and health outcomes. Funnel plots of EQIs and observational studies showed asymmetric distributions and potential for small study bias. There is some evidence that non-cognitive skills associate with improved outcomes. However, there is potential for small study and publication bias that may over-estimate true effects, and heterogeneity of effect estimates spanned negative, null and positive effects. The quality of evidence from EQIs under-pinning this field is lower than optimal and more than a third of observational studies made little or no attempt to control confounding. Interventions designed to develop children's non-cognitive skills could potentially improve outcomes. The inter-disciplinary researchers interested in these skills should take a more strategic and rigorous approach to determine which interventions are most effective.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people.

BACKGROUND: Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated. OBJECTIVES: To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people. SEARCH METHODS: We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations. SELECTION CRITERIA: We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level. DATA COLLECTION AND ANALYSIS: We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies. AUTHORS' CONCLUSIONS: Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

The association between A Body Shape Index and mortality: Results from an Australian cohort.

It is well recognised that obesity increases the risk of premature death. A Body Shape Index (ABSI) is a formula that uses waist circumference (WC), body mass index (BMI) and height to predict risk of premature mortality, where a high score (Quartile 4) indicates that a person's WC is more than expected given their height and weight. Our study examines the association between ABSI quartiles and all-cause-, cardiovascular- and cancer-related mortality, and primary cause of death. Self-reported demographic and biomedically measured health-related risk factor and weight data was from the baseline stage of the North West Adelaide Health Study (1999-2003, n = 4056), a longitudinal cohort of Australian adults. Death-related information was obtained from the National Death Index. Primary cause of death across ABSI quartiles was examined. The association between mortality and ABSI (quartile and continuous scores) was investigated using a Cox proportional hazards survival model and adjusting for socioeconomic, and self-reported and biomedical risk factors. The proportion of all three types of mortality steadily increased from ABSI Quartile 1 through to Quartile 4. After adjusting for demographic and health-related risk factors, the risk of all-cause mortality was higher for people in ABSI Quartile 4 (HR 2.64, 95% CI 01.56-4.47), and ABSI Quartile 3 (HR 1.95, 95% CI 1.15-3.33), with a moderate association for the continuous ABSI score (HR 1.32, 95% CI 1.18-1.48). ABSI is therefore positively associated with mortality in Australian adults. Different combined measures of obesity such as the ABSI are useful in examining mortality risk.