Enhancing Social-Emotional Health and Wellbeing in the Early Years (E-SEE): a study protocol of a community-based randomised controlled trial with process and economic evaluations of the incredible years infant and toddler parenting programmes, delivered in a proportionate universal model.

INTRODUCTION: Behavioural and mental disorders have become a public health crisis and by 2020 may surpass physical illness as a major cause of disability. Early prevention is key. Two Incredible Years (IY) parent programmes that aim to enhance child well-being and development, IY Infant and IY Toddler, will be delivered and evaluated in a proportionate universal intervention model called Enhancing Social-Emotional Health and Wellbeing in the Early Years (E-SEE) Steps. The main research question is: Does E-SEE Steps enhance child social emotional well-being at 20 months when compared with services as usual? METHODS AND ANALYSIS: E-SEE Steps will be delivered in community settings by Early Years Children's Services and/or Public Health staff across local authorities. Parents of children aged 8 weeks or less, identified by health visitors, children's centre staff or self-referral, are eligible for participation in the trial. The randomisation allocation ratio is 5:1 (intervention to control). All intervention parents will receive an Incredible Years Infant book (universal level), and may be offered the Infant and/or Toddler group-based programme/s-based on parent depression scores on the Patient Health Questionnaire or child social emotional well-being scores on the Ages and Stages Questionnaire: Social Emotional, Second Edition (ASQ:SE-2). Control group parents will receive services as usual. A process and economic evaluation are included. The primary outcome for the study is social emotional well-being, assessed at 20 months, using the ASQ:SE-2. Intention-to-treat and per protocol analyses will be conducted. Clustering and hierarchical effects will be accounted for using linear mixed models. ETHICS AND DISSEMINATION: Ethical approvals have been obtained from the University of York Education Ethics Committee (ref: FC15/03, 10 August 2015) and UK NHS REC 5 (ref: 15/WA/0178, 22 May 2015. The current protocol is Version 9, 26 February 2018. The sponsor of the trial is the University of York. Dissemination of findings will be via peer-reviewed journals, conference presentations and public events. TRIAL REGISTRATION NUMBER: ISRCTN11079129; Pre-results.

Maternal Education, Changing Family Circumstances, and Children's Skill Development in the United States and UK.

Among the core dimensions of socioeconomic status, maternal education is the most strongly associated with children's cognitive development, and is a key predictor of other resources within the family that strongly predict children's well-being: economic insecurity, family structure, and maternal depression. Most studies examine these circumstances in isolation of one another and/or at particular points in time, precluding a comprehensive understanding of how the family environment evolves over time and contributes to educational disparities in children's skill development and learning. In addition, very little research examines whether findings observed among children in the United States can be generalized to children of a similar age in other countries. We use latent class analysis and data from two nationally representative birth cohort studies that follow children from birth to age five to examine two questions: 1) how do children's family circumstances evolve throughout early childhood, and 2) to what extent do these trajectories account for the educational gradient in child skill development? Cross-national analysis reveals a good deal of similarity between the U.S. and U.K. in patterns of family life during early childhood, and in the degree to which those patterns contribute to educational inequality in children's skill development.

Self-reported maternal parenting style and confidence and infant temperament in a multi-ethnic community: results from the Born in Bradford cohort.

Ethnic minority children in the United Kingdom often experience health disadvantage. Parenting influences children's current and future health, but little is known about whether parenting behaviours and mother's perception of her infant vary by ethnicity. Using the Born in Bradford (BiB) birth cohort, which is located in an ethnically diverse and economically deprived UK city, we conducted a cross-sectional analysis of mother's self-reported parenting confidence, self-efficacy, hostility and warmth, and infant temperament at six months of age. We examined responses from women of Pakistani (N = 554) and White British (N = 439) origin. Pakistani mothers reported feeling more confident about their abilities as a parent. Significantly fewer Pakistani women adopted a hostile approach to parenting, an effect that was attenuated after adjustment for socioeconomic status and mental health. Overall, women with more self-efficacious, warm and less hostile parenting styles reported significantly fewer problems with their infant's temperaments. Of women with higher self-efficacy parenting styles, Pakistani mothers were significantly more likely than White British mothers to report more problematic infant temperaments, although absolute differences were small. It is unlikely that the ethnic variation seen in children's cognitive and behavioural outcomes in childhood is attributable to differences in parenting or infant characteristics reported at six months.

Psychological distress during pregnancy in a multi-ethnic community: findings from the born in Bradford cohort study.

PURPOSE: Antenatal anxiety and depression are predictive of future mental distress, which has negative effects on children. Ethnic minority women are more likely to have a lower socio-economic status (SES) but it is unclear whether SES is an independent risk factor for mental health in pregnancy. We described the association between maternal mental distress and socio-demographic factors in a multi-ethnic cohort located in an economically deprived city in the UK. METHODS: We defined eight distinct ethno-language groups (total N = 8,454) and classified a threshold of distress as the 75th centile of within-group GHQ-28 scores, which we used as the outcome for univariate and multivariate logistic regression for each ethnic group and for the sample overall. RESULTS: Financial concerns were strongly and independently associated with worse mental health for six out of the eight ethnic groups, and for the cohort overall. In some groups, factors such as working status, education and family structure were associated with worse mental health, but for others these factors were of little importance. CONCLUSIONS: The diversity between and within ethnic groups in this sample underlines the need to take into consideration individual social, migration and economic circumstances and their potential effect on mental health in ethnically diverse areas.

The psychometric properties of the subscales of the GHQ-28 in a multi-ethnic maternal sample: results from the Born in Bradford cohort.

BACKGROUND: Poor maternal mental health can impact on children's development and wellbeing; however, there is concern about the comparability of screening instruments administered to women of diverse ethnic origin. METHODS: We used confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) to examine the subscale structure of the GHQ-28 in an ethnically diverse community cohort of pregnant women in the UK (N = 5,089). We defined five groups according to ethnicity and language of administration, and also conducted a CFA between four groups of 1,095 women who completed the GHQ-28 both during and after pregnancy. RESULTS: After item reduction, 17 of the 28 items were considered to relate to the same four underlying concepts in each group; however, there was variation in the response to individual items by women of different ethnic origin and this rendered between group comparisons problematic. The EFA revealed that these measurement difficulties might be related to variation in the underlying concepts being measured by the factors. CONCLUSIONS: We found little evidence to recommend the use of the GHQ-28 subscales in routine clinical or epidemiological assessment of maternal women in populations of diverse ethnicity.

Ethnic density effects on physical morbidity, mortality, and health behaviors: a systematic review of the literature.

It has been suggested that people in racial/ethnic minority groups are healthier when they live in areas with a higher concentration of people from their own ethnic group, a so-called ethnic density effect. Ethnic density effects are still contested, and the pathways by which ethnic density operates are poorly understood. The aim of this study was to systematically review the literature examining the ethnic density effect on physical health, mortality, and health behaviors. Most studies report a null association between ethnic density and health. Protective ethnic density effects are more common than adverse associations, particularly for health behaviors and among Hispanic people. Limitations of the literature include inadequate adjustment for area deprivation and limited statistical power across ethnic density measures and study samples.

Immigrant-native differences in child health: does maternal education narrow or widen the gap?

Abundant U.S. research documents an "immigrant advantage" in children's physical health. This article extends consideration to the United Kingdom, permitting examination of a broader group of immigrants from disparate regions of the world and different socioeconomic backgrounds. Drawing on birth cohort data (ages 0-5) from both countries (n=4,139 and n=13,381), the analysis considers whether the children of immigrants have a physical and mental health advantage around the beginning of elementary school, and whether advantage is more pronounced among low-educated populations. Findings indicate that the children of immigrants are not uniformly healthier than those in native-born families. Rather, there is heterogeneity in the immigrant advantage across outcomes, and evidence of both greater advantage and disadvantage among children in low-educated immigrant families.

Impact of ethnic density on adult mental disorders: narrative review.

BACKGROUND: The 'ethnic density hypothesis' is a proposition that members of ethnic minority groups may have better mental health when they live in areas with higher proportions of people of the same ethnicity. Investigations into this hypothesis have resulted in a complex and sometimes disparate literature. AIMS: To systematically identify relevant studies, summarise their findings and discuss potential explanations of the associations found between ethnic density and mental disorders. METHOD: A narrative review of studies published up to January 2011, identified through a systematic search strategy. Studies included have a defined ethnic minority sample; some measure of ethnic density defined at a geographical scale smaller than a nation or a US state; and a measure ascertaining mental health or disorder. RESULTS: A total of 34 papers from 29 data-sets were identified. Protective associations between ethnic density and diagnosis of mental disorders were most consistent in older US ecological studies of admission rates. Among more recent multilevel studies, there was some evidence of ethnic density being protective against depression and anxiety for African American people and Hispanic adults in the USA. However, Hispanic, Asian-American and Canadian 'visible minority' adolescents have higher levels of depression at higher ethnic densities. Studies in the UK showed mixed results, with evidence for protective associations most consistent for psychoses. CONCLUSIONS: The most consistent associations with ethnic density are found for psychoses. Ethnic density may also protect against other mental disorders, but presently, as most studies of ethnic density have limited statistical power, and given the heterogeneity of their study designs, our conclusions can only be tentative.

Do risk factors for post-partum smoking relapse vary according to marital status?

We aimed to examine associations between factors readily obtainable in health care settings and post-partum smoking relapse in women of differing marital status. We analysed data on 1,829 mothers in the Millennium Cohort Study who reported quitting smoking during their pregnancy using multivariate logistic regression. We analysed single, married and cohabiting women separately. Fifty-seven percent of mothers who quit during pregnancy had relapsed at 9 months. The risk of relapse was highest for single women, followed by cohabiting, then married women. Higher parity and not managing financially were associated with relapse for single women. For married women the greatest risk of relapse was associated with having a partner who also relapsed. Women whose husbands continued to smoke had an increased risk of relapse but those whose husbands had sustained a quit were protected. Other significant risk factors were not breastfeeding, having other children and drinking at moderate frequencies. A similar pattern was seen for cohabiting women, except that having a partner who quit but then relapsed did not appear to confer an additional risk. Drinking at moderate intervals (only) was associated with relapse but breastfeeding and parity were not. The association between married couple relapse was not evident when only the husband's smoking status during the pregnancy was considered, indicating that partner follow-up is important post-partum. Risk factors for relapse appear to differ according to marital status. A 'one size fits all' package of post-partum relapse prevention is unlikely to be an appropriate intervention strategy.

The anti-nonGal xenoantibody response to alpha1,3-galactosyltransferase gene knockout pig xenografts.

PURPOSE OF REVIEW: Anti-nonGal xenoantibodies are a major barrier to the survival of genetically modified porcine xenografts. This review summarizes the contribution of anti-nonGal xenoantibodies to the activation of porcine endothelial cells and graft rejection, and further provides an update on recent advancements in defining the unique features of anti-nonGal xenoantibody structure. RECENT FINDINGS: Anti-nonGal xenoantibodies pre-exist at low levels in humans and nonhuman primates, and are notably absent in neonates. Exposure of nonhuman primates to alpha1,3-galactosyltransferase gene knockout endothelial cells initiates an induced xenoantibody response that is restricted and encoded by the germline immunoglobulin heavy chain gene IGHV3-21. The target xenoantigen remains undetermined, but several candidate targets have been proposed, including carbohydrate xenoantigens. New advancements in molecular modeling provide insight on the mechanism by which xenoantibodies bind to structurally related carbohydrates. SUMMARY: Genetic manipulation of porcine donors has significantly prolonged the survival of grafts placed into nonhuman primate recipients, but anti-nonGal xenoantibodies and thrombosis limit the ability of these grafts to function on a long-term basis. Recent developments defining pre-existing anti-nonGal xenoantibody levels, the restriction in the anti-nonGal xenoantibody response and the identification of key sites defining xenoantibody-carbohydrate interactions now provide the information necessary to develop new approaches to preventing xenoantibody-mediated rejection.

Parents' mental health and children's cognitive and social development: families in England in the Millennium Cohort Study.

BACKGROUND: The development of children of parents who are experiencing mental health difficulties is a continuing cause of concern for professionals working in health, social care and education as well as policy makers. In light of this interest our study investigates the interplay between the mental health of mothers and fathers and family socioeconomic resources, and the impact for children's cognitive and social development. METHODS: The study uses survey data from the Millennium Cohort Study linked with the Foundation Stage Profile assessment for children in the primary year of school in England between 2005 and 2006. The study includes 4,781 families from England where both parents' mental health had been assessed using the Kessler 6 scale. Associations between parents' mental health and children's cognitive and social development were estimated using regression models. Multivariate models were used to explore the mediating role of the families' socioeconomic resources. Gender interaction models were used to explore whether effects of parents' mental health differ for girls and boys. RESULTS: The study finds lower attainment in communication, language and literacy, mathematical development and personal, social and emotional development among children whose parents were experiencing high levels of psychological distress. Parents' age and qualifications and families' socioeconomic resources strongly mediated the effects of parents' psychological distress on children's attainment, and although independent effects of mother's mental health were maintained, effects of father's mental health were not. Stronger effects of mothers' mental health were found for boys than for girls. CONCLUSIONS: These findings highlight the interplay between the mental health of parents, families' socioeconomic resources and children's development which speaks for the need for close integration of mental health and social interventions to improve the well being of families.

Ethnic density effects on maternal and infant health in the Millennium Cohort Study.

Studies have suggested that members of ethnic minority groups might be healthier when they live in areas with a high concentration of people from their own ethnic group - in spite of higher levels of material deprivation typically found within such areas. We investigated the effects of area-level same-ethnic density on maternal and infant health, independent of area deprivation and individual socioeconomic status, in five ethnic minority groups. The study was a cross-sectional analysis within the UK Millennium Cohort Study and included mothers in five ethnic minority groups (Black African n=367, Bangladeshi n=369, Black Caribbean n=252, Indian n=462 and Pakistani n=868) and their 9-month-old infants. Outcome measures included: low birth weight, preterm delivery, maternal depression, self-rated health and limiting long-standing illness. Compared to those who live in areas with less than 5% of people from the same-ethnic minority population, Indian and Pakistani mothers were significantly less likely to report ever being depressed in areas with high same-ethnic density. There was a protective effect of ethnic density for limiting long-term illness among Bangladeshi mothers at 5-30% density and Pakistani mothers at all higher densities. Ethnic density was unrelated to infant outcomes and maternal self-rated health, and unrelated to any outcomes in Black African and Black Caribbean mothers and infants, possibly because no families in these groups lived at higher levels of same-ethnic density. Results were similar whether we examined smaller or larger residential areas. We conclude that, among ethnic minority mothers and infants in England, the relationship of ethnic density to health varies by ethnicity and outcome. For some measures of maternal health, in some ethnic groups, the psychosocial advantages of shared culture, social networks and social capital may override the adverse effects of material deprivation.

Economic deprivation, maternal depression, parenting and children's cognitive and emotional development in early childhood.

This study uses data from the UK Millennium Cohort Study to examine the extent to which economic circumstances in infancy and mother's mental well-being are associated with children's cognitive development and behaviour problems at age 3 years, and what part parenting behaviours and attitudes play in mediating these factors. The analyses derived from Structural Equation Modelling show that economic deprivation and maternal depression separately and collectively diminish the cognitive and emotional well-being of children, and part of this diminution emanates from less nurturing and engaged parenting by those with less economic and emotional resources.

Marital status disparities in maternal smoking during pregnancy, breastfeeding and maternal depression.

One of the dramatic recent changes in family life in Western nations has been the rise in non-marital childbearing. Much of this increase is attributable to the growth in cohabitation. But in some countries, notably the UK (and the USA) this is much less the case with significant proportions of children being born to parents who are not living together. This study uses data from the Millennium Cohort Study, a British birth cohort established in 2001, to examine whether the closeness of the tie between parents, as assessed by their partnership status at birth, is related to smoking during pregnancy, breastfeeding and maternal depression. Four sets of parents are distinguished representing a hierarchy of bonding or connectedness: married and cohabiting parents, and two groups of solo mothers, those closely involved with the father at the time of the birth and those not in a relationship. Smoking in pregnancy, breastfeeding and maternal depression tests for trend, adjusted for socio-demographic factors, showed that there was a statistically increased risk of adverse health and health behaviours by degree of parental connectedness. There were also consistent and statistically significant differences between married and non-married mothers. Particularly noteworthy was the finding that cohabiting mothers have greater risk of adverse outcomes than married women. Among the non-married set, there were also differences in risk of adverse outcomes. For smoking in pregnancy, the key difference for continuing to smoke throughout the pregnancy lay between mothers involved with partners and those lacking an intimate relationship. For breastfeeding, stronger parental bonds were associated with initiation of breastfeeding, with a clear difference between cohabiting mothers compared to solo mothers. There was also an increased risk of maternal depression with looser parental bonding, and among non-married groups this increased risk was most noticeable among cohabiting mothers when compared with solo mothers.

Parental divorce and subsequent disadvantage: a cross-cohort comparison.

Although many studies have examined the link between parental divorce and subsequent well-being, some theories of the effects of divorce suggest that the negative associations should have declined over time. However, few studies have examined the extent to which the associations have remained stable over time. Using data from two British cohorts, we analyzed both shorter- and longer-term outcomes of children who experienced parental divorce and the extent to which the associations have changed over time. Estimating similar models for both cohorts, we found little evidence of any change in the size of the relationship as divorce became more commonplace.

Preparing for an era of weapons of mass destruction (WMD)--are we there yet? Why we should all be concerned. Part II.

September 11, 2001 demonstrated dramatic voids in national preparedness, and catalyzed massive efforts to identify and remedy vulnerabilities. Since Part I of this series appeared in August 2002, significant improvements have been achieved especially in bioterrorism and chemical terrorism for first responders and emergency medicine, law enforcement, and public health (surveillance). Such efforts manifested benefits during the SARS outbreaks and monkeypox cases of 2003. Nevertheless, emerging infectious diseases will continue to pose a threat if we do not remain vigilant and continue to invest in training, surveillance, and treatments. As expected, many poison centers and toxicologists have taken leadership roles nationwide. In regions where such leadership existed, preparedness levels are strong and collaborations resulted in the development of valuable response plans and training, including the Advanced Hazardous Life Support (AHLS) and Basic Disaster Life Support (BDLS) courses. Early success notwithstanding, experts suggest that current national preparedness has improved slightly from "1" (9/11) to "3" out of "10". Increasingly it has become evident that the nuclear threat, including radiation terrorism, is significant, against which the US remains inadequately prepared. Arguably the nuclear threat-whether accidental or planned-remains our highest consequence vulnerability, and we must rapidly improve our readiness across disciplines. Special populations including the elderly and children remain marginalized in preparedness protocols. Local vulnerabilities including chemical manufacturing and transportation--not just a risk for terrorism but industrial accidents--continue unabated. Our early success is not an endpoint; much work remains and time is fleeting. This report examines vulnerabilities that must be addressed to enhance preparedness.

Unmarried parenthood: new insights from the Millennium Cohort Study.

This study uses information from the Millennium Cohort Study to examine the characteristics of families where children are born within a marriage, within a cohabiting union or outside of a co-residential partnership. For this latter group, for the first time in a national data set, an assessment can be made of the 'strength' of the parent's relationship at the time of the birth. We show that the context of childbearing varies with respect to geography, ethnicity, age, parity and educational status of the mother, and that the socioeconomic wellbeing of families varies according to the partnership status of their parents. A closer look at the non-partnered parents shows that the extent to which the fathers were involved with the mother of the child around the time the baby was born was related to the presence of the father at the birth of the child and whether his name was recorded on the child's birth certificate; as well as to subsequent behaviour, such as, whether they moved in with the mother, saw their children on a regular basis or contributed money to the child's maintenance.