Adverse childhood experiences during childhood and academic attainment at age 7 and 11 years: an electronic birth cohort study.

OBJECTIVES: Adverse childhood experiences (ACEs) have a negative impact on childhood health, but their impact on education outcomes is less well known. We investigated whether or not ACEs were associated with reduced educational attainment at age 7 and 11 years. STUDY DESIGN: The study design used in the study is a population-based electronic cohort study. METHODS: We analysed data from a total population electronic child cohort in Wales, UK. ACEs (exposures) were living with an adult household member with any of (i) serious mental illness, (ii) common mental disorder (CMD), (iii) an alcohol problem; (iv) child victimisation, (v) death of a household member and (vi) low family income. We used multilevel logistic regression to model exposure to these ACEs and not attaining the expected level at statutory education assessments, Key Stage (KS) 1 and KS2 separately, adjusted for known confounders including perinatal, socio-economic and school factors. RESULTS: There were 107,479 and 43,648 children included in the analysis, with follow-up to 6-7 years (KS1) and 10-11 years (KS2), respectively. An increased risk of not attaining the expected level at KS1 was associated with living with adult household members with CMD (adjusted odds ratio [aOR]: 1.13 [95% confidence interval [CI]: 1.09-1.17]) or an alcohol problem (adjusted odds ratio [aOR]: 1.16 [95% confidence interval [CI]: 1.10-1.22]), childhood victimisation (adjusted odds ratio [aOR]: 1.58 [95% confidence interval [CI]: 1.37-1.82]), death of a household member (adjusted odds ratio [aOR]: 1.14 [95% confidence interval [CI]: 1.04-1.25]) and low family income (adjusted odds ratio [aOR]: 1.92 [95% confidence interval [CI]: 1.84-2.01]). Similar results were observed for KS2. Children with multiple adversities had substantially increased odds of not attaining the expected level at each educational assessment. CONCLUSION: The educational potential of many children may not be achieved due to exposure to adversity in childhood. Affected children who come in to contact with services should have relevant information shared between health and care services, and schools to initiate and facilitate a coordinated approach towards providing additional support and help for them to fulfil their educational potential, and subsequent economic and social participation.

Health and mass unemployment events-developing a framework for preparedness and response.

BACKGROUND: Mass unemployment events are not uncommon yet the impact on health is not well recognised. There is a need for a preparedness and response framework, as exists for other events that threaten population health. METHODS: Framework informed by a narrative review of the impact of mass unemployment on health (studies published in English from 1990 to 2016), and qualitative data from 23 semi-structured interviews with individuals connected to historical national and international events, addressing gaps in published literature on lessons learnt from past responses. RESULTS: Economic and employment shock triggered by mass unemployment events have a detrimental impact on workers, families and communities. We present a public health informed response framework which includes (i) identify areas at risk, (ii) develop an early warning system, (iii) mobilise multi-sector action including health and community, (iv) provision of support across employment, finance and health (v) proportionate to need, (vi) extend support to family members and (vii) communities and (viii) evaluate and learn. CONCLUSION: Mass unemployment events have an adverse impact on the health, financial and social circumstances of workers, families, and communities. This is the first framework for action to mitigate and address the detrimental impact of mass unemployment events on population health.

Measuring the relationships between adverse childhood experiences and educational and employment success in England and Wales: findings from a retrospective study.

OBJECTIVES: Educational and employment outcomes are critical elements in determining the life course of individuals, yet through health and other mechanisms, those who suffer adverse childhood experiences (ACEs) may experience barriers to achieve in these domains. This study examines the association between ACEs and poor educational outcomes, before considering the impact of ACEs and education on employment in adulthood. STUDY DESIGN: Retrospective cross-sectional surveys were conducted in England and Wales using a random stratified sampling methodology. METHODS: During face-to-face household interviews (n = 2881), data were collected on demographic factors, ACEs, self-rated childhood affluence, the highest qualification level attained and the current employment status. RESULTS: While respondents with ≥4 ACEs were significantly more likely to have no formal qualifications (adjusted odds ratio [AOR] = 2.18; P < 0.001), among those who did achieve secondary level qualifications, the presence of ACEs did not further impact subsequent likelihood of going on to attain college or higher qualifications. However, results suggest a persisting independent impact of high (≥4) ACEs, which were found to be significantly associated with both current unemployment (AOR = 2.52, P < 0.001) and long-term sickness and disability (AOR = 3.94, P < 0.001). Modelled levels of not being in employment ranged from as little as 3% among those with 0 or 1 ACE and higher qualifications to 62% among those with no qualifications and ≥4 ACEs (adjusted for age, gender and childhood affluence effects). CONCLUSIONS: Compulsory education may play a pivotal role in mitigating the effects of adversity, supporting the case for approaches within schools that build resilience and tackle educational inequalities. However, adults with ACEs should not be overlooked and efforts should be considered to support them in achieving meaningful employment.

Measuring mortality and the burden of adult disease associated with adverse childhood experiences in England: a national survey.

BACKGROUND: ACE (adverse childhood experience) studies typically examine the links between childhood stressors and adult health harming behaviours. Using an enhanced ACE survey methodology, we examine impacts of ACEs on non-communicable diseases and incorporate a proxy measure of premature mortality in England. METHODS: A nationally representative survey was undertaken (n = 3885, aged 18-69, April-July 2013). Socio-demographically controlled proportional hazards analyses examined the associations between the number of ACE categories (<18 years; e.g. child abuse and family dysfunction such as domestic violence) and cancer, diabetes, stroke, respiratory, liver/digestive and cardiovascular disease. Sibling (n = 6983) mortality was similarly analysed as a measure of premature mortality. RESULTS: Of the total, 46.4% of respondents reported ≥1 and 8.3% ≥4 ACEs. Disease development was strongly associated with increased ACEs (e.g. hazard ratios, HR, 0 versus ≥4 ACEs; cancer, 2.38 (1.48-3.83); diabetes, 2.99 (1.90-4.72); stroke, 5.79 (2.43-13.80, all P < 0.001). Individuals with ≥4 ACEs (versus no ACEs) had a 2.76 times higher rate of developing any disease before age 70 years. Adjusted HR for mortality was strongly linked to ACEs (≥4 versus 0 ACEs; HR, 1.97 (1.39-2.79), P < 0.001). CONCLUSIONS: Radically different life-course trajectories are associated with exposure to increased ACEs. Interventions to prevent ACEs are available but rarely implemented at scale. Treating the resulting health costs across the life course is unsustainable.

Contribution of violence to health inequalities in England: demographics and trends in emergency hospital admissions for assault.

INTRODUCTION: Violence is increasingly recognised as a major public health issue yet health data are underutilised for describing the problem or developing responses. We use English emergency hospital admissions for assault over four years to examine assault demography and contribution to health inequalities. METHODS: Geodemographic cross-sectional analyses utilising records of all individuals in England (n = 120 643) admitted between 1 April 2002 and 31 March 2006. RESULTS: Over 4 years, rates of admission increased by 29.56% across England. Admissions peaked on Saturdays (22.34%) and Sundays (20.38%). Higher rates were associated with deprivation across all ages, including those <15 years, with a sixfold increase in admission rates between the poorest and wealthiest quintiles of residence. Logistic regression analyses indicate males are 5.59 times more likely to be admitted to hospital for assault and such admissions peak in those aged 15-29 years. Modelling based on national assault admissions and limited Accident and Emergency (A&E) data suggest that while more serious assaults requiring hospital admission have increased, assault attendances at A&Es have fallen. DISCUSSION: Hospital admission and A&E data identify a direct contribution made by violence to health inequalities. Levels of violence inhibit other interventions to improve people's health through, for instance, outdoor exercise or delivery of health-related services in affected areas. With disproportionate exposure to violence in poorer areas even in those under 15, early life primary prevention initiatives are required in disadvantaged communities to reduce childhood harm and the development of adult perpetrators and victims of violence.

How many data sources are needed to determine diabetes prevalence by capture-recapture?

BACKGROUND: Capture-recapture (CR) methods are increasingly used to estimate the size of human populations, including those with diabetes. Few studies have examined the demographic details needed to match patients on the lists used in these techniques, or to determine the optimum number of lists. METHODS: Six lists of known diabetic patients attending different medical settings during the study year were obtained. The effects on total enumeration after aggregation of these lists were examined using increasing numbers of demographic data items as patient identifiers. The CR estimates of prevalence were obtained using 15 different combinations of two lists. Estimates were obtained after log-linear modelling for interdependence between different combinations of three and four lists, and after combining the six available lists into three logical lists. RESULTS: For matching patients, adding date of birth to first name and family name as matching criteria increased the total of identified patients from 2500 to 2585 (3% increase), corresponding to a period prevalence of 1.5% (95% CI : 1.41-1.52). Addition of further identifiers, such as partial postcode, only increased the estimate by a further 15 patients (0.5%), and more detailed matching with full postcode introduced uncertainty. The use of two-list CR yielded widely varying estimates of the total diabetic population from 1379 (95% CI : 435-2273) to 9554 (95% CI : 7291-10 983). Log-linear modelling using different combinations of three and four lists produced estimates of 5074 (95% CI : 4417-5947) and 5578 (95% CI : 4918-7081), respectively, after compensating for statistical interdependence between the lists used. The appropriate condensation of six available lists into three lists for modelling yielded estimates of 5492 (95% CI : 4870-6285), corresponding to a CR-adjusted period prevalence of 3.1% (95% CI : 3.03-3.19%). CONCLUSIONS: In a Western population, the only demographic data required for matching patients on lists used for CR methods are first name, family name and date of birth, if unique identifiers such as social security numbers are not available. Two lists alone do not produce reliable data, and at least three lists are needed to allow for modelling for 'dependence' between datasets. The use of more than three lists does not substantially alter the absolute value or confidence of enumeration, and multiple lists (if available) should be condensed into three lists for use in CR calculations.

AIDS funding. The national lottery.

The government's funding of AIDS and HIV services in England is inequitable. Spending per patient in North Thames is four times that in Manchester. Deaths from AIDS in North Thames are significantly lower than in other parts of England.

Income inequality and mortality in England.

BACKGROUND: Despite the increasing evidence that income inequality causes reductions in life expectancy in developed countries, this relationship has not been explored in the United Kingdom, where local income data are not routinely available. We have surmounted this problem by employing an ecological design which applies national income data to local mortality and occupational data. METHODS: This ecological, cross-sectional study used 1991 mortality and Census data on the 366 English local government districts, and 1991 New Earnings Survey data for England, to determine the independent effect of income inequalities within English local authorities on the variation in all cause mortality between them. The subjects were all men and women recorded as economically active in the 1991 Census. We carried out linear regression analyses between all cause, all ages standardized mortality ratios, income inequality indexes and mean income levels of the local government districts. Results Both income inequality and mean income were independently associated with mortality. CONCLUSIONS: It is likely that income inequality makes an independent contribution to life expectancy in English local authorities. This finding adds further to the international evidence supporting the potentially positive health impact of increasing the scale of redistributive fiscal policies.

Historical declines in tuberculosis in England and Wales: improving social conditions or natural selection?

UNLABELLED: A reinvestigation of the relationship between the decline of tuberculosis and improvement in social conditions in England and Wales during Victorian times. DESIGN: A retrospective study using data published in the annual reports of the Registrar General from 1853 to 1910. The diseases studied, in addition to tuberculosis were, dysentery and cholera including their total and infant mortality. Social conditions were evaluated from earnings and population density per house. Tuberculosis mortality declined at an annual average rate of 1.71% (95%CI 0.77 to 2.63) whereas total mortality, infant mortality and mortality from cholera and dysentery and house population density showed no statistically significant decline over the same period. Real earnings increased by 1.05% (C10.29 to 1.81). Improving social conditions do not provide the total explanation for the decline in tuberculosis during Victorian times. Other factors, principally natural selection, probably played a role. Part of the current increase in tuberculosis may be caused by effective drug therapy eliminating natural selection.

Drug misuse services. No quick fixes.

The Department of Health's new funding formula for drug misuse services will reduce funding in districts with the highest demand for services. Some regions will receive up to four times more per reported episode of drug misuse than others. This is due, in part, to the inclusion of numbers in rented accommodation in the funding formula.