School-based learning about sugary drinks: possibilities and potential for curriculum approaches supporting health promotion in New Zealand.

Achieving greater alignment with national curriculum and local school and teacher objectives alongside a deeper understanding of student needs can enhance the impact and reach of health promotion interventions. This study reports on teacher perspectives of a multi-pathway curriculum outline supporting learning (Grades 7-9) about sugary drinks. The outline was developed to support scale-up and sustainability of a successful sugary drink intervention trialed in four New Zealand secondary schools. Sixteen teachers from a range of subjects provided input via focus groups. Inductive qualitative thematic analysis was used to identify and interpret patterns within the data. Sugary drinks were perceived to be an important and engaging learning context. Teachers valued the potential long-term societal benefits of health-based learning and benefits to individual students and their families. They recognised students as health communicators and influencers within families and communities. Relevance to students' lives and alignment with national curriculum and assessment objectives and teacher subject expertise were key factors in learning pathway selection. Teacher support is crucial in facilitating sustainable school-based health promotion, which often does not sit within a single curriculum area. Factors such as these, that teachers prioritise in their curriculum decision-making, must be understood and leveraged in school-based health promotion research.

Children's scabies survey indicates high prevalence and misdiagnosis in Auckland educational institutions.

AIM: Here, we present results of a survey of scabies prevalence in childcare centres and primary schools in Auckland. METHODS: Children whose parents agreed to take part in participating centres in the Auckland region were examined for scabies by general practitioners and given questionnaires of relevant symptoms. Diagnoses of clinical or suspected scabies were made according to the International Alliance for the Control of Scabies (IACS) criteria. The survey was a stratified random sample of schools and early childcare centres. A quantitative polymerase chain reaction (PCR) test was also used to complement the IACS criteria. RESULTS: A total of 181 children were examined, with 145 children with history information, 16 of whom (11.0%) met the criteria for 'clinical' or 'suspected' scabies. Weighted analysis, accounting for the survey design, indicated that the prevalence of scabies in early childcare centres was 13.2% (95% CI: 4.3 to 22.1), with no school-aged children fulfilling these criteria. A higher proportion had clinical signs of scabies with 23 (12.7%) having typical scabies lesions and a further 43 (23.8%) had atypical lesions. A total of 64 PCR tests were taken and 15 (23%) were positive. None of these cases were receiving treatment for scabies. Five were undergoing topical skin treatment: three with topical steroid and two with calamine lotion. CONCLUSIONS: The prevalence of children with scabies is high in early childcare centres in Auckland. Misdiagnosis is suggested by several PCR positive cases being treated by topical agents used to treat other skin conditions.

What factors are associated with early childhood dental caries? A longitudinal study of the Growing Up in New Zealand cohort.

BACKGROUND: The relative importance of different strategies to prevent dental caries is not known. AIM: We explored the relationship between oral health behaviours, diet, and the incidence of dental caries. DESIGN: We conducted a study of children participating in the 'Growing Up in New Zealand' cohort. Exposures were oral health behaviours, a food frequency questionnaire, and sociodemographic characteristics that were recorded when the child was nine months and two years old. Outcomes were records of dental caries at ages four to seven years. RESULTS: 4111 children had dental examination records from between the ages of four and seven years. High levels of dental caries were reported in children of Pacific, Asian, and Maori ethnicity. Food frequency questionnaire information was summarised into two principal components. The major axis of variation was in the intake of food and drinks with high concentrations of sugar and refined starch, with this component strongly associated with caries (multivariable incidence rate ratio of caries 0.48; 95% confidence interval: 0.38-0.61, comparing the extreme quintiles of the first principal component). CONCLUSIONS: A diet high in sugar or refined starch was strongly linked to caries. Policies to reduce sugar and refined starch intake should be considered.

I was truly addicted to sugar: A consumer-focused classification system of behaviour change strategies for sugar reduction.

The reduction of free sugars has been identified as a priority issue internationally. A range of public health initiatives have been recommended, including the provision of information and support for sugar reduction. To inform these approaches, it is important to know what people actually do in real world settings to reduce their consumption. This study documents and defines the range of consumer-based behaviour change strategies for sugar reduction. A total of 1145 strategies were extracted from 47 internet sources (i.e., consumer, popular and professional). Using a pragmatic content analysis, hundreds of strategies were organized into 25 discrete categories of strategies. Categories were grouped into the Rubicon Model of Action Phases and classified as pre-decisional (i.e., decisional balance, feedback, realisation, seek knowledge and information), post-decisional (i.e., action planning, coping planning, set goal intention, sugar guidelines) and actional phase. Actional strategies were the most prolific and included avoidance, consumption control, consumption planning, environmental restructuring, healthy eating focus, maintain readiness, professional support, refocusing, self-monitoring, social support, substance substitution, tapering, address underlying issues, urge management, well-being and withdrawal management. There was one post-actional strategy which was associated with self-evaluation (i.e., reviewing a change attempt in order to plan for the future). Four categories of strategies differed according to the source. Substance substitution was substantially less frequently discussed by consumers than professionals and few professional sites acknowledged or advised strategies to manage the struggle of maintaining readiness following a change attempt. Hundreds of individual strategies are discussed or promoted in online settings, and more information is needed on the effectiveness of these self-initiated approaches.

How strong is the relationship between scabies and acute rheumatic fever? An analysis of neighbourhood factors.

AIM: Recent studies have linked scabies with acute rheumatic fever (ARF). We explored the relationship, by neighbourhood, between permethrin dispensing as an indicator of scabies prevalence and ARF cases over the same period. METHODS: Incident cases of ARF notified to public health between September 2015 and June 2018 and the annual incidence of prescribing by neighbourhood over the same period were analysed. Evidence of an association between permethrin and ARF was obtained by carrying out Poisson regression of the rate of ARF in terms of permethrin rate at the census area unit level, with adjustment for ethnicity and socio-economic deprivation. RESULTS: A total of 413 neighbourhoods were included. The incidence of ARF varied between 0 and 102 per 100 000 people per year (mean 4.3). In contrast, the annual incidence of dispensing of permethrin varied between 0 and 3201 per 100 000 people per year (mean 771). A strong association was observed between the two variables. In an adjusted quasi-Poisson model, permethrin-dispensing rates were strongly associated with ARF incidence, with a change from the 16th to the 84th centile associated with a 16.5-fold increase in incidence (95% confidence interval: 3.82-71.6). CONCLUSIONS: Permethrin prescribing as an indicator of scabies is strongly associated with the incidence of ARF. Considered together with other studies, this evidence suggests that improving scabies control may reduce the burden of ARF in New Zealand.

How reliable is the statistical evidence for limiting saturated fat intake? A fresh look at the influential Hooper meta-analysis.

BACKGROUND: Evidence from meta-analyses has been influential in deciding whether or not limiting saturated fat intake reduces the incidence of cardiovascular disease. Recently, random effects analyses have been criticised for exaggerating the influence of publication bias and an alternative proposed which obviates this issue: 'inverse-variance heterogeneity'. AIMS: We re-analysed the influential Hooper meta-analysis that supports limiting saturated fat intake to decide whether or not the results of the study were sensitive to the method used. METHODS: Inverse-variance heterogeneity analysis of this summary study was carried out, and the results contrasted with standard methods. Publication bias was also considered. RESULTS: Inverse variance heterogeneity analysis of the Hooper combined cardiovascular disease end point results returned a pooled relative risk of 0.93 (95% confidence interval: 0.74-1.16). This finding contrasts with the traditional random effects analysis with the corresponding statistic of 0.83 (95% confidence interval: 0.72-0.96). Egger tests, funnel and Doi plots along with recently published suppressed trial results suggest that publication bias is present. CONCLUSIONS: This study questions the use of the Hooper study as evidence to support limiting saturated fat intake. Our re-analysis, together with concordant results from other meta-analyses of trials indicate that routine advice to reduce saturated fat intake in people with (or at risk for) cardiovascular disease be reconsidered.

Scabies is strongly associated with acute rheumatic fever in a cohort study of Auckland children.

AIM: This study sought to determine whether scabies infection is associated with acute rheumatic fever (ARF) or chronic rheumatic heart disease (CRHD). METHODS: A cohort study was undertaken using health records of children aged 3-12 years attending an oral health service for the first time. Subjects were then linked to hospital diagnoses of scabies and ARF or CRHD. RESULTS: A total of 213 957 children free of rheumatic heart disease at baseline were available for analysis. During a mean follow-up time of 5.1 years, 440 children were diagnosed with ARF or CRHD in hospital records. Children diagnosed with scabies during follow-up were 23 times more likely to develop ARF or CRHD, compared with children who had no scabies diagnosis. After adjustment for confounders in a Cox model, the association reduced but remained strong (adjusted hazard ratio: 8.98; 95% confidence interval: 6.33-20.2). In an analysis restricted to children hospitalised at least once during follow-up, the adjusted hazard ratio for the same comparison was 3.43 (95% confidence interval: 1.85-6.37). CONCLUSIONS: A recent diagnosis of scabies from hospital records is strongly associated with a subsequent diagnosis of ARF. Further investigation of the role that scabies infestation may play in the aetiology of ARF is warranted.

Low sugar nutrition policies and dental caries: A study of primary schools in South Auckland.

AIM: The study assessed whether a healthy food policy implemented in one school, Yendarra Primary, situated in a socio-economically deprived area of South Auckland, had improved student oral health by comparing dental caries levels with students of similar schools in the same region with no such policy. METHODS: Records of caries of the primary and adult teeth were obtained between 2007 and 2014 for children attending Yendarra, and were compared to those of eight other public schools in the area, with a similar demographic profile. Children were selected between the ages of 8 and 11 years. Linear regression models were used to estimate the strength of association between attending Yendarra school and dental caries. RESULTS: During the study period, 3813 records were obtained of children who attended dental examinations and the schools of interest. In a linear model, mean number of carious primary and adult teeth were 0.37 lower (95% confidence interval: 0.09-0.65) in Yendarra school children, compared to those in other schools, after adjustment for confounders. Pacific students had higher numbers of carious teeth (adjusted ß coefficient: 0.25; 95% confidence interval: 0.03-0.46) than Maori. CONCLUSION: This nutrition policy, implemented in a school in the poorest region of South Auckland, which restricted sugary food and drink availability, was associated with a marked positive effect on the oral health of students, compared to students in surrounding schools. We recommend that such policies are a useful means of improving child oral health.

Is serum urate causally associated with incident cardiovascular disease?

OBJECTIVE: With studies reporting both positive and negative associations, the influence of serum urate on incident cardiovascular disease (CVD) is uncertain. We sought to determine whether serum urate is causally associated with incident CVD. METHODS: Participants were aged 30-80 years and were screened for CVD risk in primary care between 2006 and 2009. Participants had blood pressure, lipids, age and ethnic group recorded at assessment, with record linkage providing drug dispensing, hospital diagnoses and laboratory test results. Outcomes were derived from hospital diagnoses and mortality records until December 2009. Cox models were used to assess the influence of exposures on outcomes. RESULTS: A total of 78 707 people, free of CVD, were enrolled, and 1328 CVD events occurred during follow-up. Serum urate was recorded before baseline assessment in 43% (34 008/78 707) of participants. After adjustment for confounding factors, a 2 s.d. difference in serum urate (0.45 vs 0.27 mmol/l) was associated with a hazard ratio (HR) of 1.56 (95% CI 1.32, 1.84). This was more than double that of the equivalent distributional change in high-density lipoprotein cholesterol (adjusted HR 1.22) and one-third greater than that for HbA1c (adjusted HR 1.41). CONCLUSION: Serum urate is likely to be causally associated with CVD. This supports public health action to reduce urate levels in populations with significant burdens of the disease.

Indoor air pollution levels were halved as a result of a national tobacco ban in a New Zealand prison.

INTRODUCTION: Few studies have measured the effect of tobacco bans on secondhand smoke (SHS) exposure in prisons. From June 1, 2011, the sale of tobacco was prohibited in New Zealand prisons. One month later, the possession of tobacco was banned. We studied the indoor air quality before and after this policy was enforced. METHODS: We measured indoor-fine-particulate (PM(2.5)) concentrations using a TSI SidePak photometer. The instrument was placed in a staff base of a New Zealand maximum-security prison, adjacent to four 12-cell wings. Measurements were made before the sales restriction, during this period, and after the ban. Data were summarized using daily geometric means and generalized least squares regression. RESULTS: A total of 7,107 observations were recorded at 5-min intervals, on 14 days before and 15 days after implementation, between 24 May and 5 August. Before the policy was implemented, the geometric mean was 6.58 µg/m(3) (95% CI = 6.29-6.58), which declined to 5.17 µg/m(3) (95% CI = 4.93-5.41) during the sales ban, and fell to 2.44 µg/m(3) (95% CI = 2.37-2.52) after the smoking ban. Regression analyses revealed an average 57% (95% CI = 42-68) decline in PM(2.5) concentrations, comparing the before and after periods. CONCLUSIONS: Our study showed a rapid and substantial improvement in indoor air quality after tobacco was banned at a prison. We conclude that prisoners have reduced their smoking in line with the ban, and that a significant health hazard has been reduced for staff and prisoners alike.

National prevalence of gout derived from administrative health data in Aotearoa New Zealand.

OBJECTIVE: Previous small studies in Aotearoa New Zealand have indicated a high prevalence of gout. This study sought to determine the prevalence of gout in the entire Aotearoa New Zealand population using national-level health data sets. METHODS: We used hospitalization and drug dispensing claims for allopurinol and colchicine for the entire Aotearoa New Zealand population from the Aotearoa New Zealand Health Tracker (ANZHT) to estimate the prevalence of gout in 2009, stratified by age, gender, ethnicity and socio-economic status (n = 4 295 296). RESULTS: were compared with those obtained from an independent large primary care data set (HealthStat, n = 555 313). Results. The all-ages crude prevalence of diagnosed gout in the ANZHT population was 2.69%. A similar prevalence of 2.89% was observed in the HealthStat population standardized to the ANZHT population for age, gender, ethnicity and deprivation. Analysis of the ANZHT population showed that gout was more common in Maori and Pacific people [relative risk (RR) 3.11 and 3.59, respectively], in males (RR 3.58), in those living in the most socio-economically deprived areas (RR 1.41) and in those aged >65 years (RR >40) (P-value for all <0.0001). The prevalence of gout in elderly Maori and Pacific men was particularly high at >25%. CONCLUSION: Applying algorithms to national administrative data sets provides a readily available method for estimating the prevalence of a chronic condition such as gout, where diagnosis and drug treatment are relatively specific for this disease. We have demonstrated high gout prevalence in the entire Aotearoa New Zealand population, particularly among Maori and Pacific people.

Potential unmet need for gout diagnosis and treatment: capture-recapture analysis of a national administrative dataset.

OBJECTIVE: To estimate the degree of undercount of people diagnosed with gout in administrative datasets using capture-recapture methods. METHODS: Hospitalization and drug dispensing claims (allopurinol or colchicine) data for all Aotearoa New Zealand were used to estimate the prevalence of gout in 2009 (n = 4 295 296). As a comparison, we calculated gout prevalence using a large primary care dataset using general practitioner diagnosis and prescribing records (n = 555 313). For each of these datasets, we estimated the undercount through capture-recapture analysis using a Poisson regression model. A two-list model was used, which included covariates such as age, gender, ethnic groups and New Zealand deprivation quintiles. RESULTS: The crude prevalence of diagnosed gout in the Aotearoa New Zealand population aged ≥ 20 years was 3.75%. The covariate-adjusted capture-recapture estimate of those not recorded but likely to have gout was 0.92%, giving an overall estimated prevalence of 4.67% (95% CI 4.49, 4.90%) for the population aged ≥ 20 years. This amounts to 80% of people with gout being identified by the algorithm for the Aotearoa New Zealand data-that is being recorded in either lists of dispensing of allopurinol or colchicine or hospital discharge. After capture-recapture, gout prevalence for all males aged ≥ 20 years was 7.3% and in older (≥ 65 years) Maori and Pacific men was >30%. CONCLUSION: Capture-recapture analysis of administrative datasets provides a readily available method for estimating an aspect of unmet need in the population-in this instance potentially 20% of those with gout not being identified and treated specifically for this condition.

Statin use in COPD patients is associated with a reduction in mortality: a national cohort study.

AIMS: To assess whether statin use is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD). METHODS: Hospitalisation, drug dispensing, and mortality records were linked for New Zealanders aged 50-80 years discharged from hospital with a first admission with COPD in 2006. Patients were classified according to whether or not they were prescribed statins prior to admission. Baseline characteristics were compared and hazard ratios calculated for statin users versus statin non-users for all-cause mortality over follow-up of up to 4 years. RESULTS: A total of 1,687 patients (mean age 70.6 years) were followed, including 596 statin users and 1,091 non-users. There were more men in the statin user group (58.4% vs. 48.5%), and statin users were more likely to have a history of cardiovascular disease (58.6% vs. 25.1%), prescription for frusemide as a proxy for heart failure (47.7% vs. 24.5%) or diabetes (35.4% vs.11.6%) than statin non-users (p<0.001). A total of 671 deaths occurred during the follow-up period. After adjustment for age, sex, ethnic group, history of cardiovascular disease, diabetes, and prescription for frusemide, the hazard ratio for statin users vs. statin non-users for all-cause mortality was 0.69 (95% CI 0.58 to 0.84). CONCLUSIONS: Statin use is associated with a 30% reduction in all-cause mortality at 3-4 years after first admission for COPD, irrespective of a past history of cardiovascular disease and diabetes.

High prevalence of scabies in Auckland pre-schools.

AIM: Scabies is a difficult disease to diagnose and its prevalence not well established. A strong association between scabies and more serious illnesses in children, for instance acute rheumatic fever, suggests greater understanding of scabies prevalence is warranted. Here, we present initial findings of a study of childcare centres, to estimate the prevalence of scabies in the Auckland community. METHODS: Children in three childcare centres from socio-economically challenged areas were examined for scabies. Diagnoses were made according to the International Alliance for the Control of Scabies (IACS) criteria, whose "clinical" or "suspected" definition consists of examination findings of papules: either "typical" or "atypical" distribution, along with history features of itch and contact with likely other cases. A quantitative polymerase chain reaction (qPCR) test was also used. RESULTS: A total of 67 children were examined, with over half (n=38 or 56.7%) showing signs of typical (14; 20.9%) or atypical (24; 35.8%) scabies lesions. History information was available for 50 children. Of these, nine (18%) met the criteria for "clinical" or "suspected" scabies. Of 27 qPCR tests performed nine (33%) tested positive. CONCLUSION: The prevalence of scabies is high in early childcare centres in socio-economically challenged areas of Auckland.

Alcohol and risk of admission to hospital for unintentional cutting or piercing injuries at home: a population-based case-crossover study.

BACKGROUND: Cutting and piercing injuries are among the leading causes of unintentional injury morbidity in developed countries. In New Zealand, cutting and piercing are second only to falls as the most frequent cause of unintentional home injuries resulting in admissions to hospital among people aged 20 to 64 years. Alcohol intake is known to be associated with many other types of injury. We used a case-crossover study to investigate the role of acute alcohol use (i.e., drinking during the previous 6 h) in unintentional cutting or piercing injuries at home. METHODS: A population-based case-crossover study was conducted. We identified all people aged 20 to 64 years, resident in one of three regions of the country (Greater Auckland, Waikato and Otago), who were admitted to public hospital within 48 h of an unintentional non-occupational cutting or piercing injury sustained at home (theirs or another's) from August 2008 to December 2009. The main exposure of interest was use of alcohol in the 6-hour period before the injury occurred and the corresponding time intervals 24 h before, and 1 week before, the injury. Other information was collected on known and potential confounders. Information was obtained during face-to-face interviews with cases, and through review of their medical charts. RESULTS: Of the 356 participants, 71% were male, and a third sustained injuries from contact with glass. After adjustment for other paired exposures, the odds ratio for injury after consuming 1 to 3 standard drinks of alcohol during the 6-hour period before the injury (compared to the day before), compared to none, was 1.77 (95% confidence interval 0.84 to 3.74), and for four or more drinks was 8.68 (95% confidence interval 3.11 to 24.3). Smokers had higher alcohol-related risks than non-smokers. CONCLUSIONS: Alcohol consumption increases the odds of unintentional cutting or piercing injury occurring at home and this risk increases with higher levels of drinking.

Per capita sugar consumption is associated with severe childhood asthma: an ecological study of 53 countries.

AIMS: To examine the ecological association between population asthma symptom prevalence in six to seven year-old children and per capita sugar consumption seven years earlier (during the perinatal period). METHODS: The asthma data (from the International Study of Asthma and Allergies in Childhood [ISAAC] study) were collected between 1999 and 2004 from 53 countries, and per capita sugar consumption data (seven years before the asthma prevalence) were extracted from United Nations Food and Agriculture (UNFAO) food balance sheets. Linear regression and Spearman's rank coefficient were used to evaluate the relationship between exposure and disease outcome. RESULTS: Per capita sugar consumption varied more than six fold-between countries. A log-linear relationship was found between severe asthma symptoms (%) and per capita added sugar consumption in kg/capita/year (exponentiated beta coefficient 1.020; 95% CI 1.005 to 1.034; P = 0.012). Spearman's rank correlation coefficient was 0.34 (P= 0.015), which indicates moderate correlation. CONCLUSIONS: We have demonstrated an ecological association between sugar consumption during the perinatal period and subsequent risk of severe asthma symptoms in six and seven year-olds.

Estimating the effect of selective border relaxation on COVID-19 in New Zealand.

AIMS: We developed a model, updated daily, to estimate undetected COVID-19 infections exiting quarantine following selectively opening New Zealand's borders to travellers from low-risk countries. METHODS: The prevalence of infectious COVID-19 cases by country was multiplied by expected monthly passenger volumes to predict the rate of arrivals. The rate of undetected infections entering the border following screening and quarantine was estimated. Level 1, Level 2 and Level 3 countries were defined as those with an active COVID-19 prevalence of up to 1/105, 10/105 and 100/105, respectively. RESULTS: With 65,272 travellers per month, the number of undetected COVID-19 infections exiting quarantine is 1 every 45, 15 and 31 months for Level 1, Level 2 and Level 3 countries, respectively. The overall rate of undetected active COVID-19 infections exiting quarantine is expected to increase from the current 0.40 to 0.50 per month, or an increase of one extra infection every 10 months. CONCLUSIONS: Loosening border restrictions results in a small increase in the rate of undetected COVID-19 infections exiting quarantine, which increases from the current baseline by one infection every 10 months. This information may be useful in guiding decision-making on selectively opening of borders in the COVID-19 era.

Gamification and Sugar: A School-Based Pilot Study of Social Marketing and Gamification Approaches to Reduce Sugary Drink Intake in Pasifika School Students.

The aim of this study was to investigate a social marketing-gamification intervention to reduce sugary drink intake drawing on popular culture of Pasifika secondary school students in Auckland, New Zealand. Students aged 11 to 14 years from one coeducational high school participated in the 11-week pilot study. The 9-week intervention was undertaken in assemblies and classrooms. Baseline and follow-up measures were completed by 227 and 220 students, respectively, of 298 enrolled students. Retention of the "3-6-9" teaching related to maximum daily sugar intake increased from 9% at baseline to 97% at follow-up (P < .0001). Significant increases were observed of students who correctly answered sugar content of drinks. Overall consumption of sugary drink decreased at follow-up by 0.46 glasses per day. The main conclusion from this study was that this school-based gamification educational package to convey messages about sugar content of drinks using popular modes of engagement is a promising intervention that was acceptable and well supported by school staff and students.