The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis.

Background: A recent study has shown that close to one in six older adults have experienced elder abuse in a community setting in the past year. It is thought that abuse in institutions is just as prevalent. Few systematic evidence of the scale of the problem exists in elder care facilities. The aim of this review is to conduct a systematic review and meta-analysis of the problem in institutional settings and to provide estimates of the prevalence of elder abuse in the past 12 months. Methods: Fourteen academic databases and other online platforms were systematically searched for studies on elder abuse. Additionally, 26 experts in the field were consulted to identify further studies. All studies were screened for inclusion criteria by two independent reviewers. Data were extracted, and meta-analysis was conducted. Self-reported data from older residents and staff were considered separately. Results: Nine studies met the inclusion criteria from an initial of 55 studies identified for review. Overall abuse estimates, based on staff reports, suggest that 64.2% of staff admitted to elder abuse in the past year. There were insufficient studies to calculate an overall prevalence estimate based on self-reported data from older residents. Prevalence estimates for abuse subtypes reported by older residents were highest for psychological abuse (33.4%), followed by physical (14.1%), financial (13.8%), neglect (11.6%), and sexual abuse (1.9%). Conclusions: The prevalence of elder abuse in institutions is high. Global action to improve surveillance and monitoring of institutional elder abuse is vital to inform policy action to prevent elder abuse.

Child maltreatment prevention: a content analysis of European national policies.

Background: Child maltreatment is a major public health concern, which worsens inequalities and perpetuates social injustice through its far-reaching impacts on the health and development of children affected. The aim of this article was to provide a content analysis of the national policies presently used to address child maltreatment and provide an overview of prevention practices being employed in countries of the World Health Organization (WHO) European Region. This analysis will aid in identifying, which policy areas still require further work to prevent child maltreatment. Methods: Three search methods were employed to identify national policies on child maltreatment. A framework based on WHO guidelines for the development of policies was used to conduct a policy analysis of the identified national policies. Results: Two hundred and seventy-eight national policies were identified; of these, 68 met the inclusion criteria for further analysis representing 75% of the WHO Europe Region Member States. Whereas the majority of policies fulfilled most of the WHO criteria for effective policy-making, only 34% had a budget and 6% had quantified objectives. Plans to implement proven child maltreatment prevention interventions were high, with the exception of some countries where the health sector is in the lead. Conclusions: The key policy areas requiring improvement were quantifiable objectives and allocated defined budgets. Hospital-based and home-based child maltreatment interventions were also not widely planned for implementation. Encouraging progress is being made on national policy development to prevent child maltreatment. There are as of yet, several key areas, which warrant increased attention in future policy-making.

Adverse childhood experiences, childhood relationships and associated substance use and mental health in young Europeans.

BACKGROUND: Adverse childhood experiences (ACEs) can increase risks of health-harming behaviours and poor health throughout life. While increases in risk may be affected by resilience resources such as supportive childhood relationships, to date few studies have explored these effects. METHODS: We combined data from cross-sectional ACE studies among young adults (n = 14 661) in educational institutions in 10 European countries. Nine ACE types, childhood relationships and six health outcomes (early alcohol initiation, problem alcohol use, smoking, drug use, therapy, suicide attempt) were explored. Multivariate modelling estimated relationships between ACE counts, supportive childhood relationships and health outcomes. RESULTS: Almost half (46.2%) of participants reported ≥1 ACE and 5.6% reported ≥4 ACEs. Risks of all outcomes increased with ACE count. In individuals with ≥4 ACEs (vs. 0 ACEs), adjusted odds ratios ranged from 2.01 (95% CIs: 1.70-2.38) for smoking to 17.68 (95% CIs: 12.93-24.17) for suicide attempt. Supportive childhood relationships were independently associated with moderating risks of smoking, problem alcohol use, therapy and suicide attempt. In those with ≥4 ACEs, adjusted proportions reporting suicide attempt reduced from 23% with low supportive childhood relationships to 13% with higher support. Equivalent reductions were 25% to 20% for therapy, 23% to 17% for problem drinking and 34% to 32% for smoking. CONCLUSIONS: ACEs are strongly associated with substance use and mental illness. Harmful relationships are moderated by resilience factors such as supportive childhood relationships. Whilst ACEs continue to affect many children, better prevention measures and interventions that enhance resilience to the life-long impacts of toxic childhood stress are required.

Growing inequalities in child injury deaths in Europe.

In this short report, we describe and compare mortality data for injuries in children aged <15 years in the WHO European region as estimated by the WHO Global Health Estimates for 2000 and 2011. Child injury deaths have decreased overall. Mortality rate ratios between low- and middle-income countries (LMIC) and high-income countries in the region show an increase in relative inequalities for childhood deaths from unintentional injuries and a narrowing from intentional injury. This growing inequality in unintentional injury is a public health concern and calls for renewed efforts to reduce childhood injuries in LMIC the region.

Advanced training in trauma life support for ambulance crews.

BACKGROUND: There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised. OBJECTIVES: To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients. SEARCH METHODS: The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists. SELECTION CRITERIA: Randomised controlled trials, controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients. DATA COLLECTION AND ANALYSIS: Two review authors assessed study reports against the inclusion criteria, and extracted data. MAIN RESULTS: We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly. AUTHORS' CONCLUSIONS: At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews on patient outcomes.

Advanced trauma life support training for hospital staff.

BACKGROUND: Injury is responsible for an increasing global burden of death and disability. As a result, new models of trauma care have been developed. Many of these, though initially developed in high-income countries (HICs), are now being adopted in low and middle-income countries (LMICs). One such trauma care model is advanced trauma life support (ATLS) training in hospitals, which is being promoted in LMICs as a strategy for improving outcomes for victims of trauma. The impact of this health service intervention, however, has not been rigorously tested by means of a systematic review in either HIC or LMIC settings. OBJECTIVES: To quantify the impact of ATLS training for hospital staff on injury mortality and morbidity in hospitals with and without such a training program. SEARCH METHODS: The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists. SELECTION CRITERIA: Randomised controlled trials, controlled trials and controlled before-and-after studies comparing the impact of ATLS-trained hospital staff versus non-ATLS trained hospital staff on injury mortality and morbidity. DATA COLLECTION AND ANALYSIS: Three authors applied the eligibility criteria to trial reports for inclusion, and extracted data. MAIN RESULTS: None of the studies identified by the search met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: There is no evidence from controlled trials that ATLS or similar programs impact the outcome for victims of injury, although there is some evidence that educational initiatives improve knowledge of hospital staff of available emergency interventions. Furthermore, there is no evidence that trauma management systems that incorporate ATLS training impact positively on outcome. Future research should concentrate on the evaluation of trauma systems incorporating ATLS, both within hospitals and at the health system level, by using more rigorous research designs.

Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults.

BACKGROUND: Educational and skills-based interventions are often used to prevent relationship and dating violence among young people. OBJECTIVES: To assess the efficacy of educational and skills-based interventions designed to prevent relationship and dating violence in adolescents and young adults. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, six other databases and a trials register on 7 May 2012. We handsearched the references lists of key articles and two journals (Journal of Interpersonal Violence and Child Abuse and Neglect). We also contacted researchers in the field. SELECTION CRITERIA: Randomised, cluster-randomised and quasi-randomised studies comparing an educational or skills-based intervention to prevent relationship or dating violence among adolescents and young adults with a control. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility and risk of bias. For each study included in the meta-analysis, data were extracted independently by GF and one other review author (either CH, JN, SH or DS). We conducted meta-analyses for the following outcomes: episodes of relationship violence, behaviours, attitudes, knowledge and skills. MAIN RESULTS: We included 38 studies (15,903 participants) in this review, 18 of which were cluster-randomised trials (11,995 participants) and two were quasi-randomised trials (399 participants). We included 33 studies in the meta-analyses. We included eight studies (3405 participants) in the meta-analysis assessing episodes of relationship violence. There was substantial heterogeneity (I(2) = 57%) for this outcome. The risk ratio was 0.77 (95% confidence interval (CI) 0.53 to 1.13). We included 22 studies (5256 participants) in the meta-analysis assessing attitudes towards relationship violence. The standardised mean difference (SMD) was 0.06 (95% CI -0.01 to 0.15). We included four studies (887 participants) in the meta-analysis assessing behaviour related to relationship violence; the SMD was -0.07 (95% CI -0.31 to 0.16). We included 10 studies (6206 participants) in the meta-analysis assessing knowledge related to relationship violence; the results showed an increase in knowledge in favour of the intervention (SMD 0.44, 95% CI 0.28 to 0.60) but there was substantial heterogeneity (I(2) = 52%). We included seven studies (1369 participants) in the meta-analysis assessing skills related to relationship violence. The SMD was 0.03 (95% CI -0.11 to 0.17). None of the included studies assessed physical health, psychosocial health or adverse outcomes. Subgroup analyses showed no statistically significant differences by intervention setting or type of participants. The quality of evidence for all outcomes included in our meta-analysis was moderate due to an unclear risk of selection and detection bias and a high risk of performance bias in most studies. AUTHORS' CONCLUSIONS: Studies included in this review showed no evidence of effectiveness of interventions on episodes of relationship violence or on attitudes, behaviours and skills related to relationship violence. We found a small increase in knowledge but there was evidence of substantial heterogeneity among studies. Further studies with longer-term follow-up are required, and study authors should use standardised and validated measurement instruments to maximise comparability of results.

Advanced trauma life support training for ambulance crews.

BACKGROUND: There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised. OBJECTIVES: To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients. SEARCH STRATEGY: Searches were not restricted by date, language or publication status. We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE (Ovid SP), EMBASE (Ovid SP), CINAHL (EBSCO) and PubMed in all years up to July 2009. We also searched the reference lists of relevant studies and reviews in order to identify unpublished material. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients. DATA COLLECTION AND ANALYSIS: One review author applied eligibility criteria to trial reports for inclusion and extracted data. MAIN RESULTS: We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly. AUTHORS' CONCLUSIONS: At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews.

Prevalence of adverse childhood experiences (ACE) in the Czech Republic.

A cross-sectional survey was undertaken to estimate the prevalence of child maltreatment and adverse childhood experiences in the Czech Republic, as data on these is scarce. The survey was conducted among 1760 randomly selected students from five Czech universities. Participants filled in the adverse childhood experiences survey instrument. The results showed that the prevalence of child maltreatment and other adverse childhood experiences is high: emotional abuse was reported by 20.7%, physical abuse by 17.1%, sexual abuse by 6.4%, and physical neglect by 8.0%. Household dysfunction was also high, with household street drug use reported by 4.9%, alcohol misuse by 15.3%, mental disorder by 13.4%, parental violence by 22.1% and parental separation by 23%. Thirty-eight per cent had not experienced any adverse childhood experience, while 9.9% reported experiencing four or more types of adverse childhood experiences. There was a significant association between adverse childhood experiences and health-harming behaviours such as suicide attempt, drug use, risky sexual behaviour and tobacco use. The findings suggest that there is a need to invest in prevention programmes.

Advanced trauma life support training for hospital staff.

BACKGROUND: Injury is responsible for an increasing global burden of death and disability. As a result, new models of trauma care have been developed. Many of these, though initially developed in high-income countries (HICs), are now being adopted in low and middle-income countries (LMICs). One such trauma care model is advanced trauma life support (ATLS) training in hospitals, which is being promoted in LMICs as a strategy for improving outcomes for victims of trauma. The impact of this health service intervention, however, has not been rigorously tested by means of a systematic review in either HIC or LMIC settings. OBJECTIVES: To quantify the impact of ATLS training for hospital staff on injury mortality and morbidity in hospitals with and without such a training program. SEARCH STRATEGY: We searched the CENTRAL, MEDLINE, EMBASE, PUBMED, CINAHL and ZETOC databases and the Cochrane Injuries Group's Specialised Register. For this update, the search strategy was expanded to include more parameters on research methodology and was run for all years to September 2008. SELECTION CRITERIA: Randomised controlled trials, controlled trials and controlled before-and-after studies comparing the impact of ATLS-trained hospital staff versus non-ATLS trained hospital staff on injury mortality and morbidity. DATA COLLECTION AND ANALYSIS: One author applied the eligibility criteria to trial reports for inclusion, and extracted data. MAIN RESULTS: There is a limited amount of literature about this topic. None of the studies identified by the search met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: There is no clear evidence that ATLS or similar programs impact the outcome for victims of injury, although there is some evidence that educational initiatives improve knowledge of hospital staff of available emergency interventions. Furthermore, there is no evidence that trauma management systems that incorporate ATLS training impact positively on outcome. Future research should concentrate on the evaluation of trauma systems incorporating ATLS, both within hospitals and at the health system level, by using more rigorous research designs.

Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis.

BACKGROUND: An increasing number of studies are identifying associations between adverse childhood experiences (ACEs) and ill health throughout the life course. We aimed to calculate the proportions of major risk factors for and causes of ill health that are attributable to one or multiple types of ACE and the associated financial costs. METHODS: In this systematic review and meta-analysis, we searched for studies in which risk data in individuals with ACEs were compared with these data in those without ACEs. We searched six electronic databases (MEDLINE, CINAHL, PsycINFO, Applied Social Sciences Index and Abstracts, Criminal Justice Databases, and the Education Resources Information Center) for quantitative studies published between Jan 1, 1990, and July 11, 2018, that reported risks of health-related behaviours and causes of ill health in adults that were associated with cumulative measures of ACEs (ie, number of ACEs). We included studies in adults in populations that did not have a high risk of ACEs, that had sample sizes of at least 1000 people, and that provided ACE prevalence data. We calculated the pooled RR for risk factors (harmful alcohol use, illicit drug use, smoking, and obesity) and causes of ill health (cancer, diabetes, cardiovascular disease, respiratory disease, anxiety, and depression) associated with ACEs. RRs were used to estimate the population-attributable fractions (PAFs) of risk attributable to ACEs and the disability-adjusted life-years (DALYs) and financial costs associated with ACEs. This study was prospectively registered in PROSPERO (CRD42018090356). FINDINGS: Of 4387 unique articles found following our initial search, after review of the titles (and abstracts, when the title was relevant), we assessed 880 (20%) full-text articles. We considered 221 (25%) full-text articles for inclusion, of which 23 (10%) articles met all selection criteria for our meta-analysis. We found a pooled prevalence of 23·5% of individuals (95% CI 18·7-28·5) with one ACE and 18·7% (14·7-23·2) with two or more ACEs in Europe (from ten studies) and of 23·4% of individuals (22·0-24·8) with one ACE and 35·0% (31·6-38·4) with two or more ACEs in north America (from nine studies). Illicit drug use had the highest PAFs associated with ACEs of all the risk factors assessed in both regions (34·1% in Europe; 41·1% in north America). In both regions, PAFs of causes of ill health were highest for mental illness outcomes: ACEs were attributed to about 30% of cases of anxiety and 40% of cases of depression in north America and more than a quarter of both conditions in Europe. Costs of cardiovascular disease attributable to ACEs were substantially higher than for most other causes of ill health because of higher DALYs for this condition. Total annual costs attributable to ACEs were estimated to be US$581 billion in Europe and $748 billion in north America. More than 75% of these costs arose in individuals with two or more ACEs. INTERPRETATION: Millions of adults across Europe and north America live with a legacy of ACEs. Our findings suggest that a 10% reduction in ACE prevalence could equate to annual savings of 3 million DALYs or $105 billion. Programmes to prevent ACEs and moderate their effects are available. Rebalancing expenditure towards ensuring safe and nurturing childhoods would be economically beneficial and relieve pressures on health-care systems. FUNDING: World Health Organization Regional Office for Europe.

Impact of Adverse Childhood Experiences on Alcohol Use in Emerging Adults in Montenegro and Romania.

BACKGROUND: Aiming at generating evidence for formulating targeted and cost-effective public health interventions for the effective control of alcohol use (AU) in emerging adults in South Eastern Europe. The study's objective was to assess if alcohol users experience adverse childhood experiences (ACE) more often than non-users, and to identify which ACE victims are the most vulnerable to AU. METHODS: The data was collected in 2010-2012 in two cross-sectional studies conducted in university settings in Montenegro and Romania (overall response rate 89.1%). In the present study, 3,283 students were included. The international ACE Study Questionnaires were used as a base for study instruments for collecting information on ACEs, health behaviours, and socio-economic factors. The association between AU and individual ACEs, adjusted to background factors, was assessed by using logistic regression. RESULTS: From the child maltreatment group, three ACEs were included in the final model as statistically significantly associated with AU, all of them from physical neglect/abuse types: frequently being hit so hard to have marks or being injured (OR=1.68; p=0.012), frequently being spanked (OR=1.38; p=0.012), and frequently having no person to take to the doctor if necessary (OR=0.58; p=0.031). From the household dysfunction group, two ACEs were included in the final model: exposure to mental health problems in the household (OR=2.85; p<0.001), and living with a problematic drinker/alcoholic (OR=1.51; p=0.019). CONCLUSIONS: The effect of exposure to ACEs on AU persists into emerging adulthood. This should be considered when developing cost-effective response to AU burden through targeted interventions, in particular in settings with scarce resources.

The evolution of unintentional injury mortality among elderly in Europe.

OBJECTIVE: To compare cause-specific unintentional injury mortality trends among elderly (65+) in the European Union over a 10-year period. METHOD: Overall and cause-specific data for 23 out of the 29 EU and European Free Trade Association countries with population >/= 1,000,000 were retrieved from the World Health Organization (WHO), and age-standardized mortality rates for the first and last 3 available years of the study period were calculated. Proportional mortality changes were estimated through linear regression. RESULTS: Circa 1993, country-specific rates varied widely (>fourfold), but this gap is closing and a statistically significant downward trend in overall mortality is noted circa 2002, in about half of the countries. Rates from falls were reduced by 4.3%, from motor vehicle traffic by 3.1%, and from smoke, fire, and flames by 3.1%. DISCUSSION: A large proportion of EU countries enjoys steady declining trends by major unintentional injury mortality category. Success factors and barriers underlying these benchmarking patterns should be further explored to accelerate the process of injury reduction.

Identification of adverse childhood experiences strongly predicting suicidal behaviour among emerging adults in Montenegro and Romania: a new way to targeted cost-effective prevention.

INTRODUCTION: Aiming at generating evidence for cost-effective public health (PH) interventions for suicidal behaviour (SB) prevention in South Eastern Europe, the objective was to identify adverse childhood experiences (ACEs) most strongly predicting SB in emerging adults. METHODS: Survey data of 3283 students aged 18-29 from Montenegro and Romania were analysed by logistic regression. Based on estimation of risk-for-SB, the profiles with the highest values were identified. RESULTS: The SB odds were the highest in respondents, experienced a suicide attempt in the household (OR: 13.81; p < 0.001), and whose primary family was not complete, in particular in those with the foster family background (OR: 18.30; p = 0.001). CONCLUSIONS: Magnitude of impact on emerging adults' mental health vulnerability tends to vary considerably with individual ACEs. This should be considered carefully when developing cost-effective response to SB burden through PH interventions in particular at the times of financial crises and in scarce resources settings.

Reducing inequalities from injuries in Europe.

Injuries cause 9% of deaths and 14% of ill health in the WHO European Region. This problem is neglected; injuries are often seen as part of everyday life. However, although western Europe has good safety levels, death and disability from injury are rising in eastern Europe. People in low-to-middle-income countries in the Region are 3.6 times more likely to die from injuries than those in high-income countries. Economic and political change have led to unemployment, income inequalities, increased traffic, reduced restrictions on alcohol, and loss of social support. Risks such as movement of vulnerable populations and transfer of lifestyles and products between countries also need attention. In many countries, the public-health response has been inadequate, yet the cost is devastating to individuals and health-service budgets. More than half a million lives could be saved annually in the Region if recent knowledge could be used to prevent injuries and thus redress social injustice in this area.

Comparison of the effectiveness of trauma services provided by secondary and tertiary hospitals in Malaysia.

STUDY OBJECTIVE: The trauma services provided by 6 hospitals operating at 2 levels of care (4 secondary or district general hospitals and 2 tertiary care hospitals) in Malaysia are compared in terms of mortality and disability for direct admissions to emergency departments to test the hypothesis that care at a tertiary care hospital is better than at a district general hospital. METHODS: All cases were recruited prospectively for 1 year. The hospitals were purposefully selected as typical for Malaysia. There are 3 primary outcome measures: death, musculoskeletal impairment, and disability at discharge. Adjustment was made for potential covariates and within-hospital clustering by using multivariable random-effects logistic regression analysis. RESULTS: For direct admissions, logistic-regression-identified odds of dying were associated with older age (>55 years), odds ratio (OR) 1.9 (95% confidence interval [CI] 1.3 to 2.8); head injury, OR 2.7 (95% CI 1.9 to 3.9); arrival by means other than ambulance, OR 0.6 (95% CI 0.4 to 0.8); severe injuries (Injury Severity Score >15) at a district general hospital, OR 45.2 (95% CI 27.0 to 75.7); severe injuries at a tertiary care hospital, OR 11.2 (95% CI 7.3 to 17.3); and admission to a tertiary care hospital compared to a district general hospital if severely injured (Injury Severity Score >15), OR 0.2 (95% CI 0.1 to 0.4). Admission to a tertiary care hospital was associated with increased odds of disability (OR 1.9; 95% CI 1.5 to 2.3) and musculoskeletal impairment (OR 3.5; 95% CI 2.7 to 4.4) at discharge. CONCLUSION: Care at a tertiary care hospital was associated with reduced mortality (by 83% in severe injuries), but with a higher likelihood of disability and impairment, which has implications for improving access to trauma services for the severely injured in Malaysia and other low- and middle-income settings.

Worsening Inequalities in Child Injury Deaths in the WHO European Region.

This article compares the mortality data for injuries in children aged 0-14 years in the World Health Organization WHO European region as estimated by the WHO Global Health Estimates for 2000 and 2015. While the region has seen a decline in child mortality due to injuries over the years, inequality persists between the low- and middle-income countries and high-income countries in the region. The gap in child mortality due to unintentional injuries has widened over the years between these two socioeconomic regions, particularly in terms of road injuries. In contrast, mortality rate ratios due to intentional injuries have narrowed between 2000 and 2015. The low- and middle-income countries need to scale up their efforts in injury prevention by adopting stricter regulations and higher safety practices to narrow the East-West gap in unintentional injuries.

The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.

BACKGROUND: A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. METHODS: In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. FINDINGS: Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I2 of >75%) between estimates for almost half of the outcomes. INTERPRETATION: To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. FUNDING: Public Health Wales.

Progress in preventing injuries: a content analysis of national policies in Europe.

The aim of this paper is to provide a content analysis of national policies to address violence and injury prevention in the World Health Organization (WHO) European Region so as to inform where future improvements can be made. Multiple search methods were used to identify national policies for violence and injury prevention. Application of a framework based on a WHO guide was used for policy analysis. A multiple correspondence analysis (MCA) was additionally conducted. One hundred and twenty-three national policies were identified; of these, 80 were available in English language and analysed further. Most national policies had been developed after 2003. The majority of policies fulfilled most of the WHO criteria for effective policy-making. Policy areas requiring improvement include quantifying objectives, targeting the socio-economic gap in injury burden and increased focus on primary prevention. Results from the MCA confirmed the ones obtained with the descriptive statistics. Encouraging progress is being made in formulating national policy for violence and injury prevention within the WHO European Region. There are specific areas that warrant increasing attention in future policy development.