Innovations in public health surveillance: An overview of novel use of data and analytic methods.

Innovative data sources and methods for public health surveillance (PHS) have evolved rapidly over the past 10 years, suggesting the need for a closer look at the scientific maturity, feasibility, and utility of use in real-world situations. This article provides an overview of recent innovations in PHS, including data from social media, internet search engines, the Internet of Things (IoT), wastewater surveillance, participatory surveillance, artificial intelligence (AI), and nowcasting. Examples identified suggest that novel data sources and analytic methods have the potential to strengthen PHS by improving disease estimates, promoting early warning for disease outbreaks, and generating additional and/or more timely information for public health action. For example, wastewater surveillance has re-emerged as a practical tool for early detection of the coronavirus disease 2019 (COVID-19) and other pathogens, and AI is increasingly used to process large amounts of digital data. Challenges to implementing novel methods include lack of scientific maturity, limited examples of implementation in real-world public health settings, privacy and security risks, and health equity implications. Improving data governance, developing clear policies for the use of AI technologies, and public health workforce development are important next steps towards advancing the use of innovation in PHS.

Adverse Childhood Experiences and Education Outcomes among Adolescents: Linking Survey and Administrative Data.

It is well established that adverse childhood experiences (ACEs) are associated with detrimental health outcomes in adulthood. Less is known about the relationships between ACEs and education outcomes and among adolescents. The aim of this study was to examine the associations between ACEs and adolescents' self-reported education outcomes and provincial education assessments among adolescents in Manitoba, Canada. Data were gathered from 1002 adolescents who participated in the Well-Being and Experiences (WE) Study. A subsample of the adolescents (84%) consented to having their WE survey data linked to administrative education databases. Binary and multinomial logistic regression models were computed to examine associations between ACE history and self-reported education outcomes and provincial education assessments, adjusting for sociodemographic variables. Adolescents with an ACE history had significantly increased likelihood of having ever been suspended from school (adjusted odds ratio (aOR) = 3.33, 95% CI 1.60-6.92), of lower grades (adjusted relative risk ratio (aRRR) = 3.21, 95% CI 1.42-7.29), and of chronic school absenteeism (aRRR = 2.45, 95% CI 1.28-4.68) compared with adolescents without an ACE history after adjusting for sociodemographic variables. Findings from this study illuminate the important relationship between childhood adversity and poor education outcomes assessed directly by adolescents. Increasing awareness of the public health risk associated with ACEs and education outcomes may inform education policy and school-based interventions.

Adolescent health outcomes: associations with child maltreatment and peer victimization.

BACKGROUND: Child maltreatment (CM) and peer victimization (PV) are serious issues affecting children and adolescents. Despite the interrelatedness of these exposures, few studies have investigated their co-occurrence and combined impact on health outcomes. The study objectives were to determine the overall and sex-specific prevalence of lifetime exposure to CM and past-month exposure to PV in adolescents, and the impact of CM and PV co-occurrence on non-suicidal self-injury, suicidality, mental health disorders, and physical health conditions. METHODS: Adolescents aged 14-17 years (n = 2,910) from the 2014 Ontario Child Health Study were included. CM included physical, sexual, and emotional abuse, physical neglect, and exposure to intimate partner violence. PV included school-based, cyber, and discriminatory victimization. Logistic regression was used to compare prevalence by sex, examine independent associations and interaction effects in sex-stratified models and in the entire sample, and cumulative effects in the entire sample. RESULTS: About 10% of the sample reported exposure to both CM and PV. Sex differences were as follows: females had increased odds of CM, self-injury, suicidality, and internalizing disorders, and males had greater odds of PV, externalizing disorders, and physical health conditions. Significant cumulative and interaction effects were found in the entire sample and interaction effects were found in sex-stratified models, indicating that the presence of both CM and PV magnifies the effect on self-injury and all suicide outcomes for females, and on suicidal ideation, suicide attempts, and mental health disorders for males. CONCLUSIONS: Experiencing both CM and PV substantially increases the odds of poor health outcomes among adolescents, and moderating relationships affect females and males differently. Continued research is needed to develop effective prevention strategies and to examine protective factors that may mitigate these adverse health outcomes, including potential sex differences.

Associations between Lifetime Spanking/Slapping and Adolescent Physical and Mental Health and Behavioral Outcomes.

BACKGROUND: Many parents use physical forms of punishment, including spanking to correct perceived misbehavior. While some authors suggest spanking/slapping is a distinct and "milder" form of physical punishment, parents' use of spanking is consistently associated with poor outcomes for their children. However, less is known about the relationship between spanking/slapping and health and behavioral outcomes in adolescence independent of other childhood adversities. OBJECTIVES: The objectives of this study were to examine the associations between lifetime experiences of spanking on the bottom and/or slapping on the hand and 3 adolescent outcomes: (a) mental health disorders, (b) physical health conditions, and (c) defiant behaviors, after adjusting for other types of childhood adversities and child maltreatment. METHODS: Cross-sectional data from the provincially representative 2014 Ontario Child Health Study (N = 6,537 dwellings, response rate = 50.8%) were used. The current study focused on one selected child aged 14 to 17 years within a household (n = 1,883) with data collected from the adolescent and the parent/caregiver. Logistic regression models were used to identify associations with lifetime experiences of spanking/slapping 3 or more times (vs. 0 to 2 times). RESULTS: Lifetime spanking/slapping was independently associated with increased odds of mental health disorders, physical health conditions, and defiant behaviors in adolescence after adjusting for childhood adversities and child maltreatment (unadjusted and adjusted odds ratios ranging from 1.29 to 2.19). CONCLUSIONS: These findings suggest that lifetime spanking/slapping is uniquely associated with harmful mental, physical, and behavioral outcomes in adolescence, and efforts should focus on its prevention.

Adverse childhood experiences (ACEs) research: A bibliometric analysis of publication trends over the first 20 years.

BACKGROUND: The relative health and robustness of a field of research can be approximated by assessing peer reviewed journal publication trends for articles pertinent to the field. To date, there have been no such assessments of the burgeoning research on adverse childhood experiences (ACEs). OBJECTIVE: The overall goal of this study was to examine ACEs research trends using bibliometric methods. More specifically, we sought to describe observed publication trends of the ACEs literature from its inception in the late 1990s. We also analyzed the nature of ACEs publications with regard to key characteristics of main outcomes, levels of analysis, and populations of primary focus. METHODS: A search was conducted using Scopus to identify English language papers on ACEs published in peer-reviewed journals between 1998 and 2018. The primary field of research was determined by having independent raters code the title of the publishing journal into distinct categories. Main research outcomes were similarly coded. RESULTS: A total of 789 articles on ACEs appearing in 351 different academic journals were published between 1998 and 2018. There was considerable growth in the number of ACEs papers published over the past several years. General medicine and multidisciplinary research were the most frequent of 12 primary fields of research characterizing ACEs research. Of 16 primary outcomes on which ACEs research focused, the most common were mental health and physical health. CONCLUSION: Significant growth in ACEs research over the past several years suggest the field is thriving. Observed publication trends and publication characteristics are discussed briefly.

What type of survey research questions are identified by adults as upsetting? A focus on child maltreatment.

BACKGROUND: Research on child maltreatment is imperative to inform evidence-based prevention and intervention efforts. Nonetheless, researchers continue to face barriers due to the perceived sensitivity and possibility of harm when asking about these experiences. While studies have started to explore reactions to participating in research on sensitive topics, there are notable limitations and fewer have focused on child maltreatment. OBJECTIVE: The objective of this study was to better understand adult respondents' identification of, and reactions to, potentially upsetting questions in the context of a well-being and experiences survey, with a focus on child maltreatment. METHODS: Data were from the first wave of the Well-Being and Experiences Study in Manitoba, Canada: a computerized self-reported community-based survey of adolescents and their parents/caregivers administered individually at a research facility. The current study focused on parents/caregivers' responses (N = 1000). The study utilized a mixed methods approach with descriptive statistics and qualitative thematic analyses of open-ended responses of their perceptions of upsetting questions. RESULTS: Overall, few respondents (15.1 %) identified any questions as upsetting. Ten themes emerged in respondents' recall of upsetting questions, including maltreatment and other themes often perceived as less sensitive. Only 4% identified maltreatment-related questions as upsetting. Among those who identified any questions or maltreatment-specific questions as upsetting, most felt they were important to ask and should not be removed (92.7 %-97.5 %). These findings suggest that retrospective survey questions about experiences of child maltreatment involving adult samples are not associated with major upset and should be included in future health and social surveys.

Adverse childhood experiences (ACEs), peer victimization, and substance use among adolescents.

BACKGROUND: Adverse childhood experiences (ACEs) are common and related to substance use problems in adulthood. Less is known about these relationships in adolescence and if experiencing ACEs in addition to peer victimization (or bullying) would have an interaction or cumulative effect on the odds of adolescent substance use. METHOD: Data were used from the Well-Being and Experiences Study (The WE Study), a cross-sectional survey of adolescents aged 14-17 years (n = 1002) in Manitoba, Canada collected between July 2017 and October 2018. Statistical methods included descriptive statistics and logistic regression models. RESULTS: The prevalence of experiencing any of the 12 ACEs was 75.1 %. The prevalence of any peer victimization (monthly or more often) was 24.1 %. All individual ACEs were associated with increased odds of substance use. No significant interaction effects between ACEs and peer victimization on substance use were found. Significant cumulative effects were found, indicating that experiencing both ACEs and peer victimization, compared with experiencing ACEs only, significantly increased the odds of substance use among adolescents. CONCLUSION: The odds of substance use becomes significantly greater if the adolescent with a history of ACEs also experiences peer victimization. Further research aimed at effective prevention of ACEs, peer victimization, and substance use is needed.

Confirmatory factor analysis of adverse childhood experiences (ACEs) among a community-based sample of parents and adolescents.

BACKGROUND: Despite increased understanding of Adverse Childhood Experiences (ACEs), very little advancement has been made in how ACEs are defined and conceptualized. The current objectives were to determine: 1) how well a theoretically-derived ACEs model fit the data, and 2) the association of all ACEs and the ACEs factors with poor self-rated mental and physical health. METHODS: Data were obtained from the Well-Being and Experiences Study, survey data of adolescents aged 14 to 17 years (n = 1002) and their parents (n = 1000) in Manitoba, Canada collected from 2017 to 2018. Statistical methods included confirmatory factor analysis (CFA) and logistic regression models. RESULTS: The study findings indicated a two-factor solution for both the adolescent and parent sample as follows: a) child maltreatment and peer victimization and b) household challenges factors, provided the best fit to the data. All original and expanded ACEs loaded on one of these two factors and all individual ACEs were associated with either poor self-rated mental health, physical health or both in unadjusted models and with the majority of findings remaining statistically significant in adjusted models (Adjusted Odds Ratios ranged from 1.16-3.25 among parents and 1.12-8.02 among adolescents). Additionally, both factors were associated with poor mental and physical health. CONCLUSIONS: Findings confirm a two-factor structure (i.e., 1) child maltreatment and peer victimization and 2) household challenges) and indicate that the ACEs list should include original ACEs (i.e., physical abuse, sexual abuse, emotional abuse, emotional neglect, physical neglect, exposure to intimate partner violence (IPV), household substance use, household mental health problems, parental separation or divorce, parental problems with police) and expanded ACEs (i.e., spanking, peer victimization, household gambling problems, foster care placement or child protective organization (CPO) contact, poverty, and neighborhood safety).

In Utero Antidepressants and Neurodevelopmental Outcomes in Kindergarteners.

OBJECTIVES: To determine if in utero selective serotonin reuptake inhibitor (SSRI) or selective serotonin norepinephrine inhibitor (SNRI) exposure is associated with developmental vulnerability in kindergarten among children whose mothers were diagnosed with prenatal mood or anxiety disorder. METHODS: Linkable administrative data were used to create a population-based cohort of 266 479 mother-child dyads of children born in Manitoba, Canada, between 1996 and 2014, with follow-up through 2015. The sample was restricted to mothers who had a mood or anxiety disorder diagnosis between 90 days before conception (N = 13 818). Exposed women had ≥2 SSRI or SNRI dispensations during pregnancy (n = 2055); unexposed mothers did not have a dispensation of an SSRI or SNRI during pregnancy (n = 10 017). The Early Development Instrument (EDI) was used to assess developmental health in kindergarten children. The EDI is a 104-component kindergarten teacher-administered questionnaire, encompassing 5 developmental domains. RESULTS: Of the 3048 children included in the study who met inclusion criteria and had an EDI, 21.43% of children in the exposed group were assessed as vulnerable on 2 or more domains versus 16.16% of children in the unexposed group (adjusted odds ratio = 1.43; 95% confidence interval 1.08-1.90). Children in the exposed group also had a significant risk of being vulnerable in language and/or cognition (adjusted odds ratio = 1.40; 95% confidence interval 1.03-1.90). CONCLUSIONS: Exposure to SSRIs or SNRIs during pregnancy was associated with an increased risk of developmental vulnerability and an increased risk of deficits in language and/or cognition. Replication of results is necessary before clinical implications can be reached.

Child maltreatment and sleep problems among adolescents in Ontario: A cross sectional study.

INTRODUCTION: Child maltreatment has a negative impact on health and well-being. Healthy sleep patterns are an important indicator of health and are particularly important for adolescent growth and development. Few studies examine the relationship between child maltreatment and sleep problems using a general population, adolescent sample. The objective of the current study was to examine the relationship between five different types of child maltreatment and four sleep outcomes among adolescents. METHODS: Data were from a subset of the Ontario Child Health Study 2014, a representative sample of 14 to 17- year-olds in Ontario, Canada (n=2,910). Sexual abuse, physical abuse and exposure to intimate partner violence (EIPV) were measured using the Childhood Experiences of Violence Questionnaire (CEVQ). Emotional maltreatment and physical neglect were measured using items derived from survey questions designed for the National Longitudinal Study of Adolescent to Adult Health. Sleep outcomes included time it takes to fall asleep, waking during the night, and hours of sleep on weekdays and weekends. Models were adjusted for sociodemographic variables. RESULTS: Findings indicate that all types of child maltreatment were associated with increased odds of taking more than 10 min to fall asleep (adjusted odds ratio [AOR]: 1.21-1.58), waking more often during the night (AOR: 1.62-5.73) and fewer hours slept on weekdays (adjusted beta [AB]: -0.39 to -0.15). Child sexual abuse, emotional maltreatment, and EIPV were associated with decreased hours of sleep on weekends (AB: -0.63 to -0.28). CONCLUSION: Preventing child maltreatment may improve sleep outcomes among adolescents, thereby improving overall health and well- being.

Examining the relationships between parent experiences and youth self-reports of slapping/spanking: a population-based cross-sectional study.

BACKGROUND: Slapping/spanking is related to a number of poor health outcomes. Understanding what factors are related to the increased or decreased use of spanking/slapping is necessary to inform prevention. This study used a population-based sample to determine the prevalence of slapping/spanking reported by youth; the relationship between sociodemographic factors and slapping/spanking; and the extent to which parental exposures to victimization and maltreatment in childhood and current parental mental health, substance use and family circumstances, are associated with youth reports of slapping/spanking. METHODS: Data were from the 2014 Ontario Child Health Study, a provincially representative sample of households with children and youth aged 4-17 years. Self-reported lifetime slapping/spanking prevalence was determined using a sub-sample of youth aged 14-17 years (n = 1883). Parents/primary caregivers (i.e., person most knowledgeable (PMK) of the youth) self-reported their own childhood experiences including bullying victimization, slapping/spanking and child maltreatment, and current mental health, substance use and family circumstances including mental health functioning and emotional well-being, alcohol use, smoking, marital conflict and family functioning. Analyses were conducted in 2018. RESULTS: Living in urban compared to rural residence and family poverty were associated with decreased odds of slapping/spanking. PMK childhood experiences of physical and verbal bullying victimization, spanking, sexual abuse, emotional abuse, and exposure to physical intimate partner violence were associated with increased odds of youth reported slapping/spanking (adjusted odds ratio [AOR] ranged from 1.33-1.77). PMK experiences of physical abuse and exposure to emotional/verbal intimate partner violence in childhood was associated with decreased odds of youth reported slapping/spanking (AOR = 0.72 and 0.88, respectively). PMK's higher levels of marital conflict, languishing to moderate mental health functioning and emotional well-being, and moderate or greater alcohol use were associated with increased odds of youth reported slapping/spanking (AOR ranged from 1.36-1.61). CONCLUSIONS: It may be important to consider parent/primary caregiver's childhood experiences with victimization and maltreatment along with their current parental mental health, substance use and family circumstances when developing and testing strategies to prevent slapping/spanking.

Trauma Exposure, DSM-5 Post-Traumatic Stress Disorder, and Sexual Risk Outcomes.

INTRODUCTION: The current study examined associations between DSM-5 post-traumatic stress disorder (PTSD) and three sexual risk outcomes: presence of a sexually transmitted disease/infection, frequency of condom use, and sex with a known user of injection drugs. METHODS: Data were from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013, analyzed 2017), a nationally representative survey of non-institutionalized U.S. adults aged ≥18 years. Sexual outcomes and trauma exposure were assessed via self-report, and PTSD was assessed using a validated structured interview. Logistic and multinomial regression analyses examined associations between PTSD, PTSD symptom clusters, trauma type, and each sexual outcome. RESULTS: Lifetime PTSD was associated with increased odds of having a past-year sexually transmitted disease/infection and sex with a known injection drug user (AOR=1.54 and 1.74, respectively); fewer intrusion symptoms were associated with sometimes/fairly often condom use relative to very often. Reporting of adult sexual assault, assaultive violence, and other trauma as one's worst event was associated with increased odds of a past-year sexually transmitted disease/infection (AOR range, 1.69-4.56), whereas child maltreatment was associated with using condoms never/almost never in the past 12 months (AOR=1.40). No other significant findings emerged. CONCLUSIONS: The current study demonstrates an association between certain trauma exposures, PTSD symptoms, and an increased likelihood of sexual risk outcomes. Clinicians working with individuals with PTSD symptoms, particularly those who have been exposed to interpersonal trauma, should screen for the presence of these sequelae.