Discharge against medical advice in rural and remote emergency departments: views of healthcare providers.

INTRODUCTION: The aim of the study was to explore, in one remote hospital, emergency department healthcare providers' experience and perceptions of the factors surrounding a patient's decision to discharge against medical advice (DAMA). The secondary objective was to gain insight into staff experiences of the current protocols for managing DAMA cases and explore their recommendations for reducing DAMA incidence. METHODS: This was a cross-sectional study involving a survey and semi-structured interviews exploring healthcare providers' (n=19) perceptions of factors perceived to be influencing DAMA, current practice for managing DAMA and recommendations for practice improvements. Health professionals (doctors, nurses, Aboriginal Health Workers) all worked in the emergency department of a remote community hospital, Queensland, Australia. Responses relating to influencing factors for DAMA were provided on a three-point rating scale from 'no influence/little influence' to 'very strong influence'. DAMA management protocol responses were a three-point rating scale from 'rarely/never' to 'always'. Semi-structured interviews were conducted after the survey and explored participants' perceptions in greater detail and current DAMA management protocol. RESULTS: Feedback from the total of 19 participants across the professions presented four prominent yet interconnected themes: patient, culture, health service and health provider, and health literacy and education-related factors. Factors that were perceived to have a strong influence on DAMA events included alcohol and drug abuse (100%), a lack of culturally sensitive healthcare services (94.7%), and family commitments or obligations (89.5%). Healthcare provider recommendations for preventing DAMA presented themes of right communication, culturally safe care (right place, right time) and the right staff to support DAMA prevention. The healthcare providers described the pivotal role the Indigenous Liaison Officer (ILO) plays and the importance of this position being filled. CONCLUSION: DAMA is a multifaceted issue, influenced by both personal and hospital system-related factors. Participants agreed that the presence of ILO and/or Aboriginal Health Workers in the emergency department may reduce DAMA occurrences for Indigenous Australians who are disproportionately represented in DAMA rates, particularly in rural and remote regions of Australia.

Impact of sleep on educational outcome of Indigenous Australian children: A systematic review.

INTRODUCTION: The association between quality sleep and improved cognition is well reported in literature. However, very few studies have been undertaken to evaluate the impact of poor sleep on educational outcomes in Indigenous Australian children. OBJECTIVES: The objective of this review was to explore the association between sleep and educational outcomes of Indigenous children. METHODS: For this systematic review, a literature search covering research articles in academic databases and grey literature sources was conducted to retrieve studies published until March 2022. Eight online e-databases (PubMed, Ovid MEDLINE, CINAHL, SCOPUS, HealthinfoNet, PsycINFO, Cochrane and Google Scholar) were searched for data extraction and two appraisal tools (NIH and CREATE) were used for quality assessment. Studies that explored any aspect of sleep health in relation to educational/academic outcomes in school going Indigenous Australian children aged 5-18 were included in this study. All review articles and studies that focused on physical/ mental disabilities or parent perceptions of sleep and educational outcomes were excluded. A convergent integrated approach was used to collate and synthesize information. RESULTS: Only three studies (two cross-sectional and one longitudinal) met the eligibility criteria out of 574 articles. The sample size ranged from 21-50 of 6 to 13 year old children. A strong relationship was indicated between sleep quantity and educational outcomes, in two of the three studies. One study related the sleep fragmentation/shorter sleep schedules of short sleep class and early risers with poorer reading (B = -30.81 to -37.28, p = 0.006 to 0.023), grammar (B = -39.79 to -47.89, p = 0.012-0.013) and numeracy (B = -37.93 to -50.15, p = 0.003 to 0.022) skills compared with long sleep and normative sleep class whereas another reported no significant relation between sleep and educational outcomes. CONCLUSION: The review highlights the need for more research to provide evidence of potentially modifiable factors such as sleep and the impact these may have on academic performance.

The myth and reality of familial resemblance in dietary intake: a systematic review and meta-analysis on the resemblance of dietary intake among parent and offspring.

Background: There is a strong societal belief that parents are role models for their child's dietary behaviours in early life that may persist throughout the life course. Evidence has shown inconclusive dietary resemblance in parent-child (PC) pairs. This systematic review and meta-analysis aimed to examine dietary resemblance between parent and children. Methods: We systematically searched for studies on PC dietary resemblance, via six electronic databases (PubMed, Ovid MEDLINE, Embase, APA PsycNet, CINAHL, and Web of Science) and other grey sources of literature between 1980 and 2020. We performed quality effect meta-analysis model on transformed correlation coefficients (z) to examine the resemblance in dietary intakes including nutrient intakes, food group intakes and whole diet. Finally, the Fisher's transformed coefficient (z) was used for meta-regression analysis to identify potential moderators. Heterogeneity and inconsistency were examined using the Q and I2 statistic. The study is registered on PROSPERO, CRD42019150741. Findings: A total of 61 studies met the inclusion criteria for systematic review, 45 were included in the meta-analysis. Pooled analyses showed weak to moderate PC dietary intake associations for energy: (r: 0.19; 95% CI: 0.16, 0.22), fat (% energy): (r: 0.23; 95% CI: 0.16, 0.29), protein (% energy): (r: 0.24; 95% CI: 0.20, 0.27), carbohydrate (% energy): (r: 0.24; 95% CI: 0.19, 0.29), fruits and vegetable (g/d): (r: 0.28; 95% CI: 0.25, 0.32), confectionary food (g/d): (r: 0.20; 95% CI: 0.17, 0.23), and whole diet (r: 0.35; 95% CI: 0.28, 0.42). Dietary intakes associations by study characteristics, including population, study year, dietary assessment method, person reporting dietary intake, quality of the study, and study design were highly variable, but associations were similar between PC pairs. Interpretation: The resemblance among parent-child pairs was weak to moderate for most aspects of dietary intakes. These findings challenge the social myth that parental dietary intake behaviour shapes their child's dietary intake. Funding: None.

Trajectories of dietary patterns from pregnancy to 12 years post-pregnancy and associated maternal characteristics: evidence from the Avon Longitudinal Study of Parents and Children.

PURPOSE: Dietary patterns (DPs) during pregnancy have been well researched. However, little is known about maternal diet after pregnancy. The aim of the study was to explore maternal DPs longitudinally, examine trajectories over 12 years after pregnancy and identify associated factors. METHODS: Of 14,541 pregnant women enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC) complete dietary information was available for 5336 women. Principal components analysis (PCA) was used to derive DPs. DP scores at each time point were used to create DP trajectories using group-based trajectory modelling (GBTM). Multinomial logistic regression assessed the association with maternal factors. RESULTS: A total of six distinct DPs were identified over time with different numbers of DPs at each time point. The "healthy" and "processed" DPs persisted over the 12-year post-pregnancy. Three trajectories of "healthy" and "processed" DPs were identified from GBTM. Half the women were on the moderately healthy DP trajectory with 37% on the lower trajectory and 9% on the higher healthy DP trajectory. 59% of women were on the lower processed DP trajectory with 38% on the moderate trajectory and 3.3% on the higher processed DP trajectory. Low educational attainment, low social class and smoking in pregnancy were independently associated with being on a less favourable DP trajectory over the 12 years. CONCLUSION: Health professionals should provide support on smoking cessation along with healthy eating advice during ante-natal counselling. Continued support on eating healthily after pregnancy would be beneficial for mothers and families.

Geographical variation in the association between physical violence and sleep disturbance among adolescents: A population-based, sex-stratified analysis of data from 89 countries.

OBJECTIVE: To examine geographical variations in involvement in physical violence and sleep disturbance among adolescents. DESIGN: Cross-sectional study. SETTING: Eighty-nine low- to middle-income and high-income countries PARTICIPANTS: Adolescents 13-17 years of age. MEASUREMENTS: Multiple binary logistic regression analyses and meta-analyses were performed to assess the link between physical violence (number of physical fights) and sleep disturbance ("mostly" or "always" experienced worry-induced sleep loss). RESULTS: Among 296,212 adolescents, 8.9% reported sleep disturbance (male: 7.5%, female: 9.6%), with the highest prevalence among adolescents from the Eastern Mediterranean region (14.1%) and high-income countries (14.1%). Overall, sleep disturbance prevalence increased gradually with the increased episodes of physical violence. Adolescents who were involved in physical violence once, 2-3 times, and 4+ times were respectively 18%, 26%, and 77% more likely than their counterparts to experience sleep disturbance (1 time: OR 1.18, 95% CI 1.13-1.24; 2-3 times: 1.26, 1.20-1.34; 4+ times: 1.77, 1.66-1.88). The association between physical violence and sleep disturbance was observed in all regions and country-income groups, with the highest odds of sleep disturbance among adolescents experiencing 4+ times of physical violence in the European region (2.34, 1.17-4.67) and upper-middle-income countries (1.91, 1.73-2.11). The association of physical violence with sleep disturbance by sex was significant in all regions and country-income groups, except the European region. CONCLUSIONS: Exposure to physical violence is associated with increased odds of sleep disturbances in adolescents. School and community-level interventions, vigilance, and programs to promote violence-free environments may improve the sleep health of adolescents exposed to physical violence.

Time trends, projections, and spatial distribution of low birthweight in Australia, 2009-2030: Evidence from the National Perinatal Data Collection.

INTRODUCTION: Infants with low birthweight (LBW, birthweight <2500 g) have increased in many high-resource countries over the past two decades. This study aimed to investigate the time trends, projections, and spatial distribution of LBW in Australia, 2009-2030. METHODS: We used standard aggregate data on 3 346 808 births from 2009 to 2019 from Australia's National Perinatal Data Collection. Bayesian linear regression model was used to estimate the trends in the prevalence of LBW in Australia. RESULTS: Wefound that the prevalence of LBW was 6.18% in 2009, which has increased to 6.64% in 2019 (average annual rate of change, AARC = +0.76%). If the national trend remains the same, the projected prevalence of LBW in Australia will increase to 7.34% (95% uncertainty interval, UI = 6.99, 7.68) in 2030. Observing AARC across different subpopulations, the trend of LBW was stable among Indigenous mothers, whereas it increased among non-Indigenous mothers (AARC = +0.81%). There is also an increase among the most disadvantaged mothers (AARC = +1.08%), birthing people in either of two extreme age groups (AARC = +1.99% and +1.53% for <20 years and ≥40 years, respectively), and mothers who smoked during pregnancy (AARC = +1.52%). Spatiotemporal maps showed that some of the Statistical Area level 3 (SA3) in Northern Territory and Queensland had consistently higher prevalence for LBW than the national average from 2014 to 2019. CONCLUSION: Overall, the prevalence of LBW has increased in Australia during 2009-2019; however, the trends vary across different subpopulations. If trends persist, Australia will not achieve the Sustainable Development Goals (SDGs) target of a 30% reduction in LBW by 2030. Centering and supporting the most vulnerable subpopulations is vital to progress the SDGs and improves perinatal and infant health in Australia.

Geographical variations in the prevalence of traditional and cyberbullying and its additive role in psychological and somatic health complaints among adolescents in 38 European countries.

OBJECTIVES: To explore geographical variations in the prevalence of traditional and cyberbullying and their individual and additive role on psychological and somatic health issues of adolescents. METHODS: We used cross-sectional data from 188,003 adolescents (50.9% females; mean age 13.6 years) from the nationally representative Health Behaviour in School-aged Children 2014 survey in 38 European countries. Multivariable linear regression analyses were conducted to explore the role of bullying on health outcomes whilst meta-analyses were conducted to generate pooled regression coefficients. RESULTS: Overall, the prevalence of traditional bullying was 26.9%, ranges from 8.8% in Armenia to 49.7% in Latvia, and cyberbullying was 15.8%, ranges from 5.8% in Greece to 38.3% in Greenland. 1 in 10 (8.4%) adolescents reported experiencing both forms of bullying, with the prevalence ranging from 2.5% (Greece) to 21.0% (Greenland). Meta-analytic estimates suggest a significant role of both traditional and cyberbullying in poor somatic and psychological health issues. The additive effect of both forms of bullying was more prominent on psychological health issues (ß 0.70, 95% CI 0.66-0.74) than on somatic health issues (ß 0.50, 95% CI 0.47-0.53). These associations varied across countries. CONCLUSION: The prevalence of traditional and cyberbullying varied significantly across European countries while their individual and additive links with an increased risk of poor psychological and somatic health issues remain common in majority countries. To ensure both forms of bullying are prevented, a multifaceted approach and particular attention to mental health issues in bullying victims are needed in countries with high prevalence of bullying.

Connecting the health of country with the health of people: Application of "caring for country" in improving the social and emotional well-being of Indigenous people in Australia and New Zealand.

Emerging evidence from the western literature suggests an increasing focus on applying nature-based interventions for mental health improvements. However, in Indigenous communities, caring for country has always been central to the Indigenous way of life. Knowing that nature-based interventions effectively improve mental health outcomes, this review collated evidence on the application of caring for country in improving social and emotional well-being (SEWB) of Indigenous peoples in Australia and New Zealand. Three studies from Australia and one from New Zealand, explored the role of country or whenua (land) in the lives of Indigenous people. Participation in caring-for country activities was associated with lower levels of psychological distress and strengthened guardianship relationship with country, which positively affected SEWB. This systematic review offers preliminary evidence on the role of caring for country activities in improving the SEWB of Indigenous peoples and highlights the need for strengths-based approaches to improve the SEWB of Indigenous peoples. Funding: None.

Epidemiology of Caesarean section on maternal request in Australia: A population-based study.

OBJECTIVE: To explore the trends, determinants, and short-term maternal and neonatal health outcomes of Caesarean section on maternal request (CSMR). DESIGN: Population-based record linkage study. SETTING: Birth registry data for all births in Queensland, Australia, from 2008 to 2017. PARTICIPANTS: Pregnancies resulting in live or intrapartum stillbirth with >=20 gestational weeks and/or >=400 gm birth weight were the study population. The analytic sample was restricted to low-risk pregnancies by excluding preterm, non-cephalic pregnancies with medical risk factors. MEASUREMENTS: CSMR was defined as a first-time C-section in singleton, term pregnancies with an ICD-10-AM code of O-82/O-47. CSMR trend was reported in age-standardised rate using a join-point regression model. The determinants and perinatal outcomes of CSMR were tested against Spontaneous vaginal births (VBs) and planned VBs including assisted VBs and emergency C-sections in this group. The generalised estimating equation technique was used for regression analysis and reported in the odds ratio (OR) at a 95% Confidence Interval (CI). FINDINGS: Of total C-sections (n = 204,863), the average annual change in CSMR rate was 4.4% (95% CI: 2.1-6.7%, p<0.01) for the total pregnancies (N=613,375) Of the analytic sample (N=365568), nulliparous women with age ≥35 years (OR: 2.32,95% CI: 2.09-2.57), delivered at private hospitals (OR:4.90; 95% CI: 4.65-5.18); with mood disorders (OR: 2.15; 95% CI: 1.88-2.43) were positive and midwives birth attendant (OR 0.28; 95% CI: 0.26 to 0.30) was negative influencing factors for CSMR. In a propensity score matched sample; CSMR observed an increasedrisk of anaesthetic complications (OR: 8.00; 95% CI:1.95-32.82) and slightly reduced odds of birth asphyxia (OR:0.20;95%CI:0.06-0.60)against planned VBs while the overall incidence of birth-asphyxia was low (1.29%) However, neonatal morbidities (OR:1.61; 95% CI:1-2.59) and special care admission (OR:2.15; 95% CI:1.03-4.5) were higher after CSMR in comparison to SVBs CONCLUSION: Despite being linked with adverse perinatal health outcomes, the incidence of CSMR increased 1.75-fold during the past 10 years. Maternal educational interventions to provide adequate information, including the long-term risks and benefits of C-sections, can help reduce the growing rates of CSMR.

Longitudinal association between caesarean section birth and cardio-vascular risk profiles among adolescents in Australia.

OBJECTIVE: To examine the association of cesarean section (C-section) with cardiovascular disease (CVD) risk biomarkers among Australian children. METHODS: The Longitudinal Study of Australian Children (LSAC) birth cohort was prospectively followed for body mass index (BMI) trajectory, and then linked with CVD risk indicators of children; waist circumference (WC), systolic blood pressure (SBP), blood glucose, high-density lipoprotein (HDL), triglyceride (TG), fat mass index (FMI) and composite metabolic syndrome (CMetS) score. Multivariable linear regression analysis was done to assess the association of C-sections with CVD risk biomarkers. RESULTS: Of 1,874 study children, 30% had C-sections; the mean age (SD) was 11.50 (0.50) years, and 49% were female. Against the vaginally-born cohort, Caesarean-born children showed a higher Z- score for five of the seven CVD risk indicators in regression analysis; WC (0.15; p=0.003), SBP (0.16; p=0.003), inverse HDL (0.15; p=0.003), FMI (0.12; p=0.004), and CMetS (0.45; p=0.004) score. Children with accelerated BMI trajectory had higher CMetS scores for both the delivery types while the C-section cohort showed statistical association only (1.69; p=0.006) Conclusion: C-section was independently associated with increased CVD risk profiles of children, further increased with high BMI trajectory. Implication for public health: The chronic disease risk of C-sections should be discussed with families to reduce clinically unrequired C-sections.

Anaemia in women of reproductive age in low- and middle-income countries: progress towards the 2025 global nutrition target.

Objective: To examine trends in, and projections of, the prevalence of anaemia in women of reproductive age in low- and middle-income countries at national and subpopulation levels. Methods: We used nationally representative data from repeated cross-sectional Demographic and Health Surveys (DHS) on 1 092 512 women of reproductive age (15-49 years) from 15 low- and middle-income countries. We defined anaemia as haemoglobin < 11 g/dL for pregnant women and < 12 g/dL for non-pregnant women. We analysed data using Bayesian linear regression analyses. Findings: During 2000-2018, the prevalence of anaemia in women of reproductive age decreased in nine countries, with the highest decrease in Malawi (-2.5%), and increased in six countries, with the highest increase in Burundi (10.9%). All countries are projected to have a prevalence of anaemia ≥ 15% in 2025, with the highest level in Burundi (66.8%). The prevalence of anaemia and projection of prevalence varied between and within countries. Women's education, family wealth and place of residence had the highest impact on the current and projected prevalence rates of anaemia. Seven countries had a prevalence of anaemia ≥ 40%, which we defined as a severe public health problem, in the earliest and latest DHS and this prevalence is projected to persist in 2025. Conclusion: None of the 15 countries is likely to meet the global nutrition target of a 50% reduction in the prevalence of anaemia in women of reproductive age by 2025. Global and country leaders should reconsider nutrition policies and reallocate resources targeting countries and communities at risk.

Sleep health and its implications in First Nation Australians: A systematic review.

Understanding the state of sleep health in First Nations Australians offers timely insight into intervention and management opportunities to improve overall health and well-being. This review explored the determinants and burden of poor sleep in First Nations Australians. A systematic search was conducted to identify studies published until August 2020 in First Nations Australian adults. Nine studies (n = 2640) were included, three in community settings, six in clinical populations. Across studies compared with non-Indigenous people, 15-34% of First Nations Australians experience less than recommended hours (<7 h/night), 22% reported fragmented, irregular, and unrefreshing sleep with a high prevalence of OSA in clinical populations (39-46%). Findings show First Nations Australians are significantly more likely to report worse sleep health than Non-Indigenous Australians in all measured domains of sleep. Co-designed sleep programs and service delivery solutions are necessary to ensure timely prevention and management of sleep issues in First Nations communities which to date have been underserved. FUNDING: No external funding was provided for this work.

Why patients attend emergency department for primary care type problems: views of healthcare providers working in a remote community.

INTRODUCTION: Emergency department (ED) utilisation continues to increase, particularly for primary care presentations that do not require high level ED services. The reasons for this are complex, and research has focused on patient perspectives in choosing where to seek care rather than those of ED and general practitioner (GP) providers. This study aimed to address this gap by exploring the views of ED and GP providers regarding ED utilisation for primary care type health conditions in a small, remote Australian city with perhaps unique population demographics and service configuration. METHODS: Service providers from the ED and general practice clinics were invited to participate in focus groups and semi-structured interviews exploring their views on ED utilisation for primary-care-type health presentations. The data were analysed using thematic content analysis. RESULTS: In total, 24 healthcare providers (five GPs, seven ED practitioners, seven community nurse navigators, four Aboriginal and Torres Strait Islander Health Workers and one Indigenous Liaison Officer) participated in focus groups discussion and interviews. The analysis identified three themes: access and logistic barriers, rational decision-making and self-perceived urgency. While there was some overlap in the healthcare providers' perceptions, there were also strong differences between ED and GP groups. In particular, the ED group believed that GP services are less accessible for urgent appointments, whereas GPs believed that such arrangements were in place. Both groups agreed on the need for clear communication between the ED and general practice. CONCLUSION: ED and GP providers demonstrate similarities and differences in understanding patients' reasons for choosing which service to access. The differences may stem from ED providers' focus on offering a rapid resolution of acute presentations and GP providers' focus on offering comprehensive and continuing care. Effective communication between general practice and the ED services and clearer referral pathways may help in reducing ED utilisation for less urgent primary-care-type problems.

Geographical variations in the association between bullying victimization and sleep loss among adolescents: a population-based study of 91 countries.

OBJECTIVE: To examine geographical variations in the association between bullying victimization and sleep loss over worry among adolescents. METHODS: We used data from the Global School-based Student Health Survey conducted between 2003 and 2017 in 91 countries across the globe. Sleep loss was categorised as: none/minimum (reported never or rarely sleep loss), moderate (reported sometimes), and severe (reported most of the time or always). We obtained country-specific estimates from multiple multinomial logistic regression analyses and pooled estimates from meta-analyses. RESULTS: Of 282,036 adolescents 13-17 years of age, 28.1% (male: 25.4%, female: 31.0%) and 8.4% (male: 7.3%, female: 9.5%) of adolescents reported moderate and severe sleep loss respectively. Adolescents who frequently experienced bullying (≥3 per 30 days) reported higher prevalence of severe sleep loss. Meta-analyses showed that increased frequency of bullying victimization is associated with increased odds of sleep loss, with adolescents who experienced bullying for ≥3 days in the past 30 days were 1.65 and 2.65 times more likely than adolescents without being bullied to experience respectively moderate (OR 1.65, 95% CI: 1.59-1.72) and severe (OR 2.65, 95% CI: 2.52-2.79) sleep loss. Irrespective of sex, the association between bullying victimization and sleep loss was significant in all regions, income groups, and in all but a few countries. CONCLUSIONS: Increased frequency of bullying victimization is positively associated with increased sleep loss among adolescents. Appropriate policies and programmes to stop bullying at school could help downgrade the risk of sleep loss among adolescents.

Double burden of malnutrition among women of reproductive age in 55 low- and middle-income countries: progress achieved and opportunities for meeting the global target.

OBJECTIVE: To examine trends and projections of underweight (Body Mass Index, BMI < 18.5 kg/m2) and overweight (BMI ≥ 25.0 kg/m2) in women of reproductive age in 55 low- and middle-income countries (LMICs). METHODS: We used data from 2,337,855 women aged 15-49 years from nationally representative Demographic and Health Survey conducted between 1990 and 2018. Bayesian linear regression analyses were performed. RESULTS: During 1990-2018, the prevalence of underweight decreased in 35 countries and overweight increased in 50 countries. The highest underweight increase was in Morocco (5.5%) and overweight in Nepal (12.4%). In 2030, >20% of women in eight LMICs will be underweight, with Madagascar (36.8%), Senegal (32.2%), and Burundi (29.2%) projected to experience the highest burden of underweight. Whereas >50% of women in 22 LMICs are projected to be overweight, with Egypt (94.7%), Jordan (75.0%), and Pakistan (74.1%) projected to have the highest burden of overweight. 24 LMICs are projected to experience the double burden of malnutrition (both underweight and overweight >20%) in 2030. Noticeable variations in underweight and overweight were observed across wealth, residence, education, and age of women, with a higher rate of overweight in high-income, high-education, and urban women. These inequalities have widened in many countries and are projected to continue. The probability of eradicating overweight and underweight is nearly 0% for all countries by 2030, except Egypt is on track to eradicate underweight. CONCLUSIONS: Although the prevalence of underweight declined, this decline has been superseded by the dramatic increase of overweight. None of the 55 LMICs is likely to eradicate malnutrition in women by 2030.

Multigenerational transmission of obesity: A systematic review and meta-analysis.

There is a strong link between parental and offspring obesity status. However, the state of epidemiological evidence on multigenerational transmission of overweight/obesity, such as from grandparents to grandchildren, is relatively unknown. This systematic review collates and appraises existing evidence on multigenerational transmission of overweight/obesity and uses meta-analytic estimates for quantitative synthesis. Six electronic databases were searched for publications reporting the relationship between grandparents and their grandchildren overweight/obesity status. A total of 25 studies from 17 countries with a combined population of 238,771 study participants met the inclusion criteria. About 60% (15) of the reviewed studies reported a positive association between grandparent-grandchild (GP-GC) overweight/obesity, out of which 11 were statistically significant. Seven studies reported odds ratios of GP-GC overweight/obesity associations and were included in the meta-analysis. The pooled estimates showed a significant GP-GC association in overweight/obesity status (odds ratio [OR]: 1.79, 95% confidence interval [CI]: 1.01-2.57). Thus, the current research evidence shows that grandchildren's overweight/obesity status is associated with their grandparents' overweight/obesity status, indicating a multigenerational transmission of obesity. However, more studies, especially from developing countries, are required to assess the robustness of these findings. Future studies should also focus on the mechanisms through which this transmission occurs.

Global Variation in Hand Hygiene Practices Among Adolescents: The Role of Family and School-Level Factors.

While appropriate hand hygiene practices (HHP) are protective against infections, the paucity of evidence on global estimates and determinants of HHP in adolescents limits effective design and planning of intervention to improve HHP in young people. We examined the prevalence and correlates of HHP in adolescents. We used nationally representative data from the Global School-based Student Health Survey (2003-2017) from 92 countries. HHP were categorized as "appropriate", "inappropriate" and "lacking" based on the information about "hand washing before eating", "hand washing after using the toilet", and "hand washing with soap". Multinomial logistic regression analyses were used to assess the role of socio-demographic, health, lifestyle, school, and family-related variables in HHP. Among 354,422 adolescents (13-17 years), only 30.3% were found to practice appropriate hand hygiene. Multivariable models suggest that sedentary behavior (adjusted relative risk ratio (ARRR) 1.41, 95% CI 1.31-1.51)), and bullying victimization (ARRR 1.20, 95% CI 1.10-1.30) promoted inappropriate HHP. In contrast, parental supervision (ARRR 0.55, 95% CI 0.50-0.59) and parental bonding (ARRR 0.81, 95% CI 0.75-0.87) were protective against inappropriate HHP. From a policy perspective, hand hygiene promotion policies and programs should focus on both school (bullying, exercise) and family-level factors (parental supervision and parental bonding) factors.

Geographical variation and temporal trend in anemia among children aged 6-59 months in low- and middle-income countries during 2000-2018: forecasting the 2030 SDG target.

OBJECTIVE: To examine geographical variations, trends and projections in the prevalence of childhood anemia at national and subpopulation levels. DESIGN: Repeated cross-sectional Demographic and Health Survey (DHS) conducted during 2000-2018. SETTING: Fifty-three low- and middle-income countries (LMIC). PARTICIPANTS: Totally, 776 689 children aged 6-59 months. RESULTS: During the latest DHS rounds between 2005 and 2018, the prevalence of child anemia was > 20 % in fifty-two out of fifty-three countries and ranged from 15·9 % in Armenia in 2016 to 87·8 % in Burkina Faso in 2010. Out of thirty-six countries with at least two surveys during 2000-2018, the prevalence of child anemia decreased in twenty-two countries, highest in Zimbabwe (-4·2 %) and increased in fourteen countries, highest in Burundi (5·0 %). Based on the trend, eleven and twenty-two out of thirty-six countries are projected to experience, respectively, moderate and severe public health problem according to the WHO criteria (moderate problem: 20-39·9 % and severe problem: ≥ 40 %) due to child anemia in 2030, with the highest prevalence in Liberia (87·5 %, 95 % credible interval 52·0-98·8 %). The prevalence of child anemia varied across the mother's education and age, child sex, wealth quintiles, and place of residence, with the highest rate of child anemia among the poorest, rural and low-educated mothers. These scenarios are projected to continue. The probability of reducing child anemia at < 0·5 % by 2030 is 0 % for all study countries. CONCLUSIONS: The prevalence of child anemia varied between and within countries. None of the thirty-six LMIC is likely to eradicate child anemia by 2030.

Drivers of general practice-type presentations to the emergency department in a remote outback community.

OBJECTIVE: To estimate the number of general practice-appropriate attendances in a remote emergency department and explore the reasons for patients' choice of service. DESIGN: A four-step case study approach was adopted, focusing on hospital emergency department (ED) attendances that were potentially manageable in general practice. SETTING: A large, remote community with substantial populations of Indigenous peoples and fly-in, fly-out mining industry workers. The ED is experiencing rapid growth in demand for services for lower urgency. PARTICIPANTS: Patients attending the emergency department with lower urgency problems. INTERVENTIONS: ED attendance data for 2016 were reviewed to identify lower urgency presentations. Patient records for 400 randomly selected presentations were subject to deeper analysis. A prospective survey was conducted over 6 months of 369 ED patients with lower urgency presentations. MAIN OUTCOME MEASURES: The proportion of patients attending the ED with GP-appropriate problems and influences on their decisions to attend the ED. RESULTS: About 48% of all attendances met the agreed definition of GP-appropriate problems. About half of presentations were during the normal work hours and about half of patients stated that GP services were unavailable. Younger age, lack of information about local GP services, and perceptions of convenience contributed significantly to seeking ED care. CONCLUSION: Increasing the availability of GP services alone is unlikely to be sufficient to change service utilisation. Strategies should include raising community awareness of how and when to utilise the appropriate service, understanding different models of care, and the need to register with a general practice.