The Commercial Determinants of Violence: Identifying Opportunities for Violence Prevention through a Public Health-Based Framework Analysis.

Violence has immediate and long-term repercussions for the health of individuals and communities. Recent increases in the understanding of public health approaches to violence prevention have focused on the policies and practices of government, health, and other public sector agencies. However, the roles of commercial bodies in fostering and preventing violence remain largely unaddressed. The wealth and influence of some companies now exceeds that of many countries. Consequently, it is timely to explore the roles of commercial processes in violence. Using a conceptual framework for the commercial determinants of health, we examine seven practices: political; scientific; marketing; supply chain and waste; labor and employment; financial; and reputational management. We include areas directly linked with violence (e.g., firearms) and those that indirectly impact violence through the following: design and promotion of products; employment practices; and impacts on environment, poverty, and local resources. A range of avoidable commercial behaviors are found to increase levels of violence including the following: lobbying practices; distortion of scientific processes; polluting manufacture and supply lines; poor employee protections; financial investment in organizations and regimes associated with violence; and misleading communications and marketing. We conclude commercial actors can take action to ensure their workers, clients, suppliers, and distributors help prevent, not promote, violence. New technologies such as artificial intelligence are transforming corporate processes and products and offer opportunities to implement violence prevention through commercial developments (e.g., monitoring online content). International regulation of commercial behaviors is needed to prevent interpersonal and interstate conflict and harms to health and trade.

Measuring changes in adult health and well-being during the COVID-19 pandemic and their relationship with adverse childhood experiences and current social assets: a cross-sectional survey.

BACKGROUND: Adverse childhood experiences (ACEs) can impact mental and physical health, leaving people with less resilience to health challenges across the life-course. This study examines whether individuals' levels and changes in levels of mental health, physical health and sleep quality reported across the first year of the COVID-19 pandemic are associated with ACEs and moderated by social assets such as having trusted family and friends. METHODS: A cross-sectional household telephone survey in England (a North West local authority) and Wales (nationally) using landline and mobile numbers stratified by health areas, deprivation quintile and age group and supplemented by an online survey. Data were collected from 4,673 English and Welsh residents aged ≥ 18 years during national COVID-19 restrictions (December 2020 to March 2021). Measures included nine types of ACE; self-reported mental health, physical health and sleep quality at time of survey (in pandemic) and one-year earlier (pre-pandemic); numbers of trusted family members and friends, knowledge of community help; and COVID-19 infection. RESULTS: ACEs were strongly related to moving into poorer mental health, physical health, and sleep categories during the pandemic, with likelihoods more than doubling in those with ≥ 4 ACEs (vs. 0). ACEs were also associated with increased likelihood of moving out of poorer health and sleep categories although this was for a much smaller proportion of individuals. Individuals with more trusted family members were less likely to move into poorer health categories regardless of ACE counts. CONCLUSIONS: ACEs are experienced by large proportions of populations and are associated with poorer health even in non-pandemic situations. However, they also appear associated with greater vulnerability to developing poorer health and well-being in pandemic situations. There is a minority of those with ACEs who may have benefited from the changes in lifestyles associated with pandemic restrictions. Connectedness especially with family, appears an important factor in maintaining health during pandemic restrictions.

Comparing relationships between single types of adverse childhood experiences and health-related outcomes: a combined primary data study of eight cross-sectional surveys in England and Wales.

OBJECTIVES: Adverse childhood experiences (ACEs) show strong cumulative associations with ill-health across the life course. Harms can arise even in those exposed to a single ACE type but few studies examine such exposure. For individuals experiencing a single ACE type, we examine which ACEs are most strongly related to different health harms. DESIGN: Secondary analysis of combined data from eight cross-sectional general population ACE surveys. SETTING: Households in England and Wales. PARTICIPANTS: 20 556 residents aged 18-69 years. MEASURES: Ten self-reported outcomes were examined: smoking, cannabis use, binge drinking, obesity, sexually transmitted infection, teenage pregnancy, mental well-being, violence perpetration, violence victimisation and incarceration. Adjusted ORs and percentage changes in outcomes were calculated for each type of ACE exposure. RESULTS: Significance and magnitude of associations between each ACE and outcome varied. Binge drinking was associated with childhood verbal abuse (VA), parental separation (PS) and household alcohol problem (AP), while obesity was linked to sexual abuse (SA) and household mental illness. SA also showed the biggest increase in cannabis use (25.5% vs 10.8%, no ACEs). Household AP was the ACE most strongly associated with violence and incarceration. PS was associated with teenage pregnancy (9.1% vs 3.7%, no ACEs) and 5 other outcomes. VA was associated with 7 of the 10 outcomes examined. CONCLUSION: Exposure to a single ACE increases risks of poorer outcomes across health-harming behaviours, sexual health, mental well-being and criminal domains. Toxic stress can arise from ACEs such as physical and SA but other more prevalent ACEs (eg, VA, PS) may also contribute substantively to poorer life course health.

Associations between Adverse Childhood Experiences (ACEs) and Lifetime Experience of Car Crashes and Burns: A Cross-Sectional Study.

Unintentional injury is a significant cause of disease burden and death. There are known inequalities in the experience of unintentional injuries; however, to date only a limited body of re-search has explored the relationship between exposure to adverse childhood experiences (ACEs) and unintentional injury. Using a cross-sectional sample of the adult general public (n = 4783) in Wales (national) and England (Bolton Local Authority), we identify relationships between ACE exposure and experience of car crashes and burns requiring medical attention across the life course. Individuals who had experienced 4+ ACEs were at significantly increased odds of having ever had each outcome measured. Furthermore, compared to those with no ACEs, those with 4+ were around two times more likely to report having had multiple (i.e., 2+) car crashes and over four times more likely to report having had burns multiple times. Findings expand the evidence base for the association between ACEs and negative health consequences and emphasise the need for effective interventions to prevent ACEs and their impact on life course health and well-being. Such knowledge can also be used to develop a multifaceted approach to injury prevention.

Parental Adverse Childhood Experiences and Perpetration of Child Physical Punishment in Wales.

Child physical punishment is harmful to children and, as such, is being prohibited by a growing number of countries, including Wales. Parents' own childhood histories may affect their risks of using child physical punishment. We conducted a national cross-sectional survey of Welsh adults and measured relationships between the number of adverse childhood experiences (ACEs) parents (n = 720 with children aged < 18) had suffered during childhood and their use of physical punishment towards children. Overall, 28.2% of parents reported having ever physically punished a child, and 5.8% reported having done so recently (in the last year). Child physical punishment use increased with the number of ACEs parents reported. Parents with 4+ ACEs were almost three times more likely to have ever physically punished a child and eleven times more likely to have done so recently (vs. those with 0 ACEs). The majority (88.1%) of parents that reported recent child physical punishment had a personal history of ACEs, while over half reported recently having been hit themselves by a child. Child physical punishment is strongly associated with parents' own ACE exposure and can occur within the context of broader conflict. Prohibiting physical punishment can protect children and, with appropriate family support, may help break intergenerational cycles of violence.

Adverse Childhood Experiences and Their Relationship with Poor Sexual Health Outcomes: Results from Four Cross-Sectional Surveys.

Improving understanding of risk factors for risky sexual behaviour is fundamental to achieve better population sexual health. Exposure to adverse childhood experiences (ACEs) can increase the risk of poor sexual health outcomes, but most research is US-based. This study explored associations between ACEs and poor sexual health outcomes in the UK. Data from four cross-sectional ACE surveys with adult general populations in different regions of the UK from 2013−2015 (n = 12,788) were analysed. Data included participants' demographics, ACE exposure, and four sexual health outcomes: having early sex (<16 years), having an accidental teenage pregnancy, becoming a teenage parent, or having a lifetime diagnosis of a sexually transmitted infection. ACE count was a consistent and significant predictor of all four sexual health outcomes for both males and females, with odds of these outcomes between three and seven times higher for those with 4+ ACEs compared to those with no ACEs. Increased risks of some, but not all, sexual health outcomes were also found with higher residential deprivation, younger age, being of white ethnicity, and being born to a teenage mother. Findings highlight the need for effective interventions to prevent and ameliorate the lifelong effects of ACEs. Trauma-informed relationships and sex education, sexual health services, and antenatal/postnatal services, particularly for teenagers and young parents, could provide opportunities to prevent ACEs and support those affected. Ensuring that those living in deprived areas have access to services and that barriers to uptake are addressed is also key.

The use of mobile phone applications to enhance personal safety from interpersonal violence - an overview of available smartphone applications in the United Kingdom.

BACKGROUND: Interpersonal violence has devastating implications for individuals, families, and communities across the globe, placing a significant burden on health, justice, and social welfare systems. Smartphone technology may provide a platform for violence prevention interventions. However, evidence on the availability and user experience of smartphone applications aimed to prevent violence is underexplored. METHODS: Systematic searches of available smartphone applications marketed for personal safety and violence prevention on the Apple Store (IOS) and Google Play (Android) in the United Kingdom were run in May 2021. Relevant applications were downloaded, with data on user reviews and ratings extracted. Included applications were categorised according to their features and functions. Online user reviews were rated according to their sentiment (positive, negative, neutral) and thematically analysed. RESULTS: Of 503 applications, 86 apps met review criteria. Only 52 (61%) apps offered full functionality free of charge. Over half (52%) of apps were targeted towards the general population, with 16% targeting women and 13% targeting families. App functionality varied with 22% providing an alarm, 71% sending alerts to pre-designated contacts, 34% providing evidence capture and 26% offering educational information. Overall, 71% of applications had a user rating of four or above. For 61 apps a total of 3,820 user reviews were extracted. Over half (52.4%) of reviews were rated as having a positive sentiment, with 8.8% neutral and 38.8% negative. Key themes across user reviews included positive consequences of app use, technical and usage issues including app reliability, dissatisfaction with the financial cost of some app features and personal data and ethical issues. CONCLUSIONS: Reviews suggest that users find apps for personal safety and violence prevention useful. However, individuals also report them being unreliable, not working as described and having features that others may exploit. Findings have implications for the development of policy on apps to improve personal safety, especially given recent national policy (e.g. UK) discussions about their utility. Without the regulation or accreditation of such technology for quality assurance and reliability, emphasis needs to be placed on ensuring user safety; otherwise vulnerable individuals may continue to place reliance on untested technology in potentially dangerous circumstances.

An evaluation of a short film promoting kindness in Wales during COVID-19 restrictions #TimeToBeKind.

BACKGROUND: In response to successive COVID-19 restrictions in Wales, the Welsh ACE Support Hub launched the #TimeToBeKind campaign in March 2021. The campaign used a short film broadcast on national television and promoted on social media to encourage behaviour change for kindness. We evaluated the #TimeToBeKind campaign film to identify whether watching the film would result in increased intention to act in ways that promote kindness to others and if intentions were associated with being emotionally affected by the film. METHODS: A mixed methods evaluation was employed, using a short online survey and interaction with the film on the Twitter social media platform. The online survey measured public (n = 390) attitudes towards the film including feelings invoked, and behavioural intentions for acts of kindness as a result of viewing the film. Tweets which interacted with the film (n = 59; likes, re-tweets or comments), and tweet sentiment (positive, negative, or neutral) towards the film were also explored. RESULTS: The majority of participants reported positive attitudes to the film and agreed that they understood the campaign message (91.8%). 67.9% reported that the film made them feel upset or sad and for 22.6% the film resonated with their lockdown experience. As a result of seeing the film, 63.6% reported intentions to be kinder to others, 65.6% intended to try and help other members of their community, and 70.5% were more likely to check in on friends, family and neighbours. A higher proportion of individuals who were emotionally affected by the film (e.g. upset or sad, hopeful or encouraged, gained something positive) and those for whom the film resonated with their lockdown experience reported increased kindness behavioural intentions as a result of seeing the film. CONCLUSIONS: Film can be an effective tool to promote behaviour change for kindness. Films that provoke strong emotional reactions can still be perceived positively and lead to behaviour change. With the COVID-19 pandemic accelerating a move online for many, the findings of the present evaluation are relevant to how public health messaging can adapt and utilise this space to target individuals and promote behaviour change.

Maternal adverse childhood experiences and their association with preterm birth: secondary analysis of data from universal health visiting.

BACKGROUND: Being born before full gestation can have short-term and life-long health implications, yet it remains difficult to determine the risk of preterm birth among expectant mothers. Across different health settings, increasing attention is given to the health and behavioural consequences of adverse childhood experiences (ACEs) such as child abuse or neglect, or exposure to harmful household environments (e.g. in which caregivers abuse alcohol), and the potential value of understanding these hidden harms when supporting individuals and families. A large international evidence base describes the association between childhood adversity and early years outcomes for mothers and children. However, the relationship between maternal ACEs and preterm birth has received far less attention. METHODS: Secondary analysis was carried out on anonymised cross-sectional data from health visiting services in south and west Wales that had previously captured information on mothers' ACEs during routine contacts. Demographic data and information on mothers' health were extracted from the Healthy Child Wales Programme. RESULTS: Half of all mothers sampled had experienced at least one ACE, with a history of ACEs more common among younger, white British mothers and those residing in deprived areas. Preterm birth was significantly independently associated with retrospective reports of childhood sexual abuse (adjusted odds ratio [AOR] = 3.83, 95% confidence interval [CI] = 1.19-12.32, p = 0.025), neglect (AOR = 7.60, 95%CI = 1.81-31.97, p = 0.006) and overall ACE exposure (AOR = 2.67, 95%CI = 1.14-6.23, p = 0.024), with one in ten mothers (10.0%) who experienced ≥4 ACEs having preterm birth. Sub-analyses revealed a more pronounced relationship among mothers with no known chronic health conditions, with those with ≥4 ACEs and no known chronic condition four times more likely to give birth preterm (AOR = 3.89, 95%CI = 1.40-10.80, p = 0.009). CONCLUSIONS: Findings highlight the importance of the entire maternal experience. The experience of childhood adversity can have a lasting impact into and beyond the prenatal period, potentially increasing the risk of preterm birth, even among otherwise healthy women. Increasing our understanding of the potential perinatal outcomes associated with ACEs can help to inform how maternity services and partners offer trauma-sensitive support to mitigate some of the risks of early parturition, as well as target intergenerational cycles of adversity and poor health.

Associations between adverse childhood experiences, attitudes towards COVID-19 restrictions and vaccine hesitancy: a cross-sectional study.

OBJECTIVES: Adverse childhood experiences (ACEs) can affect life-course health and well-being, including risk-taking behaviour and trust. This study explored associations between ACEs and trust in health information on COVID-19, attitudes towards and compliance with COVID-19 restrictions and vaccine hesitancy. DESIGN: National cross-sectional telephone survey using a sample of landline and mobile numbers stratified by Health Board, deprivation quintile and age group. SETTING: Households in Wales during national COVID-19 restrictions (December 2020 to March 2021). PARTICIPANTS: 2285 Welsh residents aged ≥18 years. MEASURES: Nine ACEs; low trust in National Health Service (NHS) COVID-19 information; supporting removal of social distancing and mandatory face coverings; breaking COVID-19 restrictions; and vaccine hesitancy (rejection or uncertainty of vaccination). RESULTS: Increasing ACE counts were independently related to low trust in NHS COVID-19 information, feeling unfairly restricted by government and ending mandatory face coverings. High ACE counts (4+ vs 0 ACEs) were also associated with supporting removal of social distancing. Breaking COVID-19 restrictions increased with ACE count with likelihood doubling from no ACEs to 4+ ACEs. Vaccine hesitancy was threefold higher with 4+ ACEs (vs 0 ACEs) and higher in younger age groups. Thus, modelled estimates of vaccine hesitancy ranged from 3.42% with no ACEs, aged ≥70 years, to 38.06% with 4+ ACEs, aged 18-29 years. CONCLUSIONS: ACEs are common across populations of many countries. Understanding how they impact trust in health advice and uptake of medical interventions could play a critical role in the continuing response to COVID-19 and controlling future pandemics. Individuals with ACEs suffer greater health risks throughout life and may also be excluded from interventions that reduce infection risks. While pandemic responses should consider how best to reach those suffering from ACEs, longer term, better compliance with public health advice is another reason to invest in safe and secure childhoods for all children.

Health and financial costs of adverse childhood experiences in 28 European countries: a systematic review and meta-analysis.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with increased health risks across the life course. We aimed to estimate the annual health and financial burden of ACEs for 28 European countries. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, CINAHL, PsycINFO, Applied Social Sciences Index and Abstracts, Criminal Justice Databases, and Education Resources Information Center for quantitative studies (published Jan 1, 1990, to Sept 8, 2020) that reported prevalence of ACEs and risks of health outcomes associated with ACEs. Pooled relative risks were calculated for associations between ACEs and harmful alcohol use, smoking, illicit drug use, high body-mass index, depression, anxiety, interpersonal violence, cancer, type 2 diabetes, cardiovascular disease, stroke, and respiratory disease. Country-level ACE prevalence was calculated using available data. Country-level population attributable fractions (PAFs) due to ACEs were generated and applied to 2019 estimates of disability-adjusted life-years. Financial costs (US$ in 2019) were estimated using an adapted human capital approach. FINDINGS: In most countries, interpersonal violence had the largest PAFs due to ACEs (range 14·7-53·5%), followed by harmful alcohol use (15·7-45·0%), illicit drug use (15·2-44·9%), and anxiety (13·9%-44·8%). Harmful alcohol use, smoking, and cancer had the highest ACE-attributable costs in many countries. Total ACE-attributable costs ranged from $0·1 billion (Montenegro) to $129·4 billion (Germany) and were equivalent to between 1·1% (Sweden and Turkey) and 6·0% (Ukraine) of nations' gross domestic products. INTERPRETATION: Availability of ACE data varies widely between countries and country-level estimates cannot be directly compared. However, findings suggest ACEs are associated with major health and financial costs across European countries. The cost of not investing to prevent ACEs must be recognised, particularly as countries look to recover from the COVID-19 pandemic, which interrupted services and education, and potentially increased risk factors for ACEs. FUNDING: WHO Regional Office for Europe.

Perceptions of a short animated film on adverse childhood experiences: a mixed methods evaluation.

OBJECTIVES: An evaluation of a short animated film on adverse childhood experiences (ACEs) to explore attitudes and sentiment towards the film including, for a subsample of professionals, associations between attitudes and personal experience of ACEs. DESIGN: Mixed-method exploratory design. SETTING: Professionals and the general public. PARTICIPANTS: A short online survey with 239 professionals. Interaction and user sentiment towards with the film on social media (Twitter, YouTube). PRIMARY AND SECONDARY OUTCOME MEASURES: Survey: participants' attitudes towards the film including feelings invoked, learning gained and ACE count prevalence. Twitter user and YouTube viewer sentiment (positive, negative or neutral) and interaction (likes, retweets or comments) with the film. RESULTS: Attitudes to the film were positive: 94.1% and 93.7%, respectively, agreed that it provided a helpful explanation of ACEs and trusted that the film was credible. Of those who reported ACE exposure, 88.9% agreed that those with ACEs would benefit from watching the film. Despite 50.6% reporting that the film had made them feel sad or upset, the majority (66.4%) reported they found the film hopeful or encouraging. Across 358 publicly available tweets from 313 users, 39.1% of tweets expressed positive sentiment, with only 1.4% negative (59.5% neutral). However, there was no association between tweet sentiment and interaction. Thirteen YouTube versions of the film received 171 812 views, 97.3% (n=889/914) ratings were positive (ie, 'thumbs up'). CONCLUSIONS: Despite being emotionally arousing, many professionals reflected positive impacts of the film including a perceived increased ability to discuss ACEs. Public sentiment demonstrated a positive reaction to and acceptability of the film. Understanding the professional and public response to materials developed to increase ACE awareness, such as the film explored here, is important given the growing number of international movements which seek to increase ACE awareness, prevent ACEs and mitigate their lifelong negative effects.

Adult support during childhood: a retrospective study of trusted adult relationships, sources of personal adult support and their association with childhood resilience resources.

BACKGROUND: Adverse childhood experiences (ACEs) can affect health and well-being across the life course. Resilience is an individual characteristic that is known to help negate the effect of adversities and potentially transform toxic stress into tolerable stress. Having access to a trusted adult during childhood is critical to helping children build resiliency. Here, we aim to understand the relationship between always having access to trusted adult support and childhood resilience resources, and examine which sources of personal adult support and the number of sources of adult support, best foster childhood resilience. METHODS: A Welsh national cross-sectional retrospective survey (n = 2497), using a stratified random probability sample. Data were collected via face-to-face interviews at participants' places of residence by trained interviewers. Analyses use chi-square and binary logistic regression methods. Outcome measures were childhood resilience resources, access to an always-available trusted adult, and sources of personal adult support. RESULTS: Prevalence of access to an always-available trusted adult decreased with increasing number of ACEs from 86.6% of individuals with no ACEs, to 44.4% of those with four or more ACEs (≥ 4). In addition, for those experiencing ≥ 4 ACEs, individuals with no access to a trusted adult were substantially less likely than those with access, to report childhood resilience resources. For example, for individuals with ≥ 4 ACEs, those with access to an always-available trusted adult were 5.6 times more likely to have had supportive friends and 5.7 times more likely to have been given opportunities to develop skills to succeed in life, compared to those with no access to a trusted adult. When looking at sources of personal adult support, resilience levels increased dramatically for those individuals who had either one parent only or two parents as sources of support, in comparison to those without parental support. CONCLUSIONS: Analyses here suggest strong relationships between elements of childhood resilience, constant access to trusted adults and different sources of personal adult support. While the eradication of ACEs remains unlikely, actions to strengthen childhood access to trusted adults may partially ease immediate harms and protect future generations.

Adverse childhood experiences: a retrospective study to understand their associations with lifetime mental health diagnosis, self-harm or suicide attempt, and current low mental wellbeing in a male Welsh prison population.

BACKGROUND: Prisoners are at increased risk of poor mental health and self-harming behaviours, with suicide being the leading cause of death in custody. Adverse childhood experiences (ACEs) such as child maltreatment are strong predictors of poor mental health and wellbeing yet despite high levels of ACEs in offender populations, relatively few studies have explored the relationships between ACEs and prisoners' mental health and wellbeing. We conducted an ACE survey with 468 male adult prisoners in a Welsh prison who were not currently considered to be at risk of self-harm and suicide and explored relationships between ACEs, lifetime mental illness diagnosis, self-harm (lifetime and lifetime in prison) or suicide attempt (lifetime and lifetime in prison), and current low mental wellbeing. RESULTS: Most participants (84.2%) had suffered at least one ACE and 45.5% had suffered ≥4 ACEs. Prevalence of lifetime mental illness diagnosis, self-harm (lifetime and lifetime in prison) or suicide attempt (lifetime and lifetime in prison), and current low mental wellbeing increased with exposure to ACEs. For example, 2.7% of those with no ACEs reported lifetime self-harm or suicide attempt in prison compared with 31.0% (self-harm in prison) and 18.3% (suicide attempt in prison) of those with ≥4 ACEs. Compared with participants with no ACEs, those with ≥4 ACEs were four times more likely to report lifetime mental illness diagnosis and suicide attempt, and over 10 times more likely to report lifetime self-harm than those with no ACEs. Independent of lifetime mental illness diagnosis, self-harm or suicide attempt, participants with ≥4 ACEs were almost three times more likely to have current low mental wellbeing than those with no ACEs. CONCLUSIONS: Male prisoners that have suffered multiple ACEs are substantially more likely to have lifetime mental illness diagnosis, self-harm or suicide attempt, and to have current low mental wellbeing whilst in prison. Findings suggest that trauma-informed approaches are needed in prisons to support prisoner mental health and wellbeing.

Health and financial burden of adverse childhood experiences in England and Wales: a combined primary data study of five surveys.

OBJECTIVE: To estimate the health and financial burden of adverse childhood experiences (ACEs) in England and Wales. DESIGN: The study combined data from five randomly stratified cross-sectional ACE studies. Population attributable fractions (PAFs) were calculated for major health risks and causes of ill health and applied to disability adjusted life years (DALYs), with financial costs estimated using a modified human capital method. SETTING: Households in England and Wales. PARTICIPANTS: 15 285 residents aged 18-69. OUTCOME MEASURES: The outcome measures were PAFs for single (1 ACE) and multiple (2-3 and ≥4 ACEs) ACE exposure categories for four health risks (smoking, alcohol use, drug use, high body mass index) and nine causes of ill health (cancer, type 2 diabetes, heart disease, respiratory disease, stroke, violence, anxiety, depression, other mental illness); and annual estimated DALYs and financial costs attributable to ACEs. RESULTS: Cumulative relationships were found between ACEs and risks of all outcomes. For health risks, PAFs for ACEs were highest for drug use (Wales 58.8%, England 52.6%), although ACE-attributable smoking had the highest estimated costs (England and Wales, £7.8 billion). For causes of ill health, PAFs for ACEs were highest for violence (Wales 48.9%, England 43.4%) and mental illness (ranging from 29.1% for anxiety in England to 49.7% for other mental illness in Wales). The greatest ACE-attributable costs were for mental illness (anxiety, depression and other mental illness; England and Wales, £11.2 billion) and cancer (£7.9 billion). Across all outcomes, the total annual ACE-attributable cost was estimated at £42.8 billion. The majority of costs related to exposures to multiple rather than a single ACE (ranging from 71.9% for high body mass index to 98.3% for cancer). CONCLUSIONS: ACEs impose a substantial societal burden in England and Wales. Policies and practices that prevent ACEs, build resilience and develop trauma-informed services are needed to reduce burden of disease and avoidable service use and financial costs across health and other sectors.

Public acceptability of public health policy to improve population health: A population-based survey.

BACKGROUND: For public health policies to be effective, it is critical that they are acceptable to the public as acceptance levels impact success rate. OBJECTIVE: To explore public acceptance of public health statements and examine differences in acceptability across socio-demographics, health behaviours (physical activity, diet, binge drinking and smoking), health status and well-being. METHOD: A cross-sectional survey was conducted with a nationally representative sample (N = 1001) using a random stratified sampling method. Face-to-face interviews were conducted at homes of residents in Wales aged 16+ years. Individuals reported whether they agreed, had no opinion, or disagreed with 12 public health statements. RESULTS: More than half of the sample were supportive of 10 out of 12 statements. The three statements with the greatest support (>80% agreement) reflected the importance of: a safe and loving childhood to becoming a healthy adult, schools teaching about health, and healthier foods costing less. Individuals who engaged in unhealthy behaviours were less likely to agree with some of the statements (eg 39.8% of binge drinkers agreed alcohol adverts should be banned compared to 57.6% of those who never binge drink; P < .001). CONCLUSIONS: Findings show an appetite for public health policies among the majority of the public. The relationship between supporting policies and engaging in healthy behaviours suggests a feedback loop that is potentially capable of shifting both public opinion and the opportunities for policy intervention. If a nation becomes healthier, this could illicit greater support for stronger policies which could encourage more people to move in a healthier direction.

Understanding the association between self-reported poor oral health and exposure to adverse childhood experiences: a retrospective study.

BACKGROUND: Adverse childhood experiences, including physical, sexual or emotional abuse, can have detrimental impacts on child and adult health. However, little research has explored the impact that such early life experiences have on oral health. This study examines whether experiencing adverse childhood experiences before the age of 18 years is associated with self-reported poor dental health in later life. METHODS: Using stratified random probability sampling, a household survey (N = 5307; age range 18-69 years) was conducted in the South of England (Hertfordshire, Luton and Northamptonshire). Data were collected at participants' homes using face-to-face interviews. Measures included exposure to nine adverse childhood experiences, and two dental outcomes: tooth loss (> 8 teeth lost due to dental caries or damage) and missing or filled teeth (direct or indirect restorations; > 12 missing or filled teeth). RESULTS: Strong associations were found between exposure to childhood adversity and poor dental health. The prevalence of tooth loss was significantly higher (8.3%) in those with 4+ adverse childhood experiences compared to those who had experienced none (5.0%; p < 0.05). A similar relationship was found for levels of missing or filled teeth (13.4%, 4+ adverse childhood experiences; 8.1%, none; p < 0.001). Exposure to 4+ adverse childhood experiences was associated with a higher level of tooth loss and restorations at any age, compared to individuals who had not experienced adversity. Demographically adjusted means for tooth loss increased with adverse childhood experience count in all age groups, rising from 1.0% (18-29 years) and 13.0% (60-69 years) in those with none, to 3.0% and 26.0%, respectively in those reporting 4+. CONCLUSIONS: Exposure to childhood adversity could be an important predictive factor for poor dental health. As oral health is an important part of a child's overall health status, approaches that seek to improve dental health across the life-course should start with safe and nurturing childhoods free from abuse and neglect. Given the growing role that dental professionals have in identifying violence and abuse, it seems appropriate to raise awareness in the field of dentistry of the potential for individuals to have suffered adverse childhood experiences, and the mechanisms linking childhood adversity to poor dental health.

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.

Ideal, expected and perceived descriptive norm drunkenness in UK nightlife environments: a cross-sectional study.

BACKGROUND: Drunkenness is common in nightlife environments and studies suggest it can be considered both desirable and normal by nightlife users. We aimed to compare UK nightlife users' ideal levels of drunkenness to their expected drunkenness on a night out and their perceptions of descriptive nightlife norms. METHODS: A cross-sectional survey with nightlife patrons (n = 408, aged 18-35) in three cities. Using a scale from 1 (completely sober) to 10 (very drunk), participants rated: personal drunkenness at survey; expected drunkenness on leaving nightlife; perceived descriptive drunkenness norm in the city's nightlife; and ideal personal drunkenness. Analyses were limited to those who had or were intending to consume alcohol. RESULTS: Almost half of participants (46.8%) expected to get drunker than their reported ideal level on the night of survey, rising to four fifths of those with the highest levels of expected drunkenness. 77.9% rated typical nightlife drunkenness ≥8 but only 40.9% expected to reach this level themselves and only 23.1% reported their ideal drunkenness as ≥8. Higher expected drunkenness was associated with higher ideal drunkenness, higher perceived drunkenness norm and later expected home time. CONCLUSIONS: Nightlife users' perceptions of typical drunkenness in nightlife settings may be elevated and many of the heaviest drinkers are likely to drink beyond their ideal level of drunkenness. Findings can support emerging work to address cultures of intoxication in nightlife environments and suggest that interventions to correct misperceptions of normal levels of nightlife drunkenness may be of benefit.

The evidence base for routine enquiry into adverse childhood experiences: A scoping review.

BACKGROUND: Exposure to adverse childhood experiences (ACEs; e.g., maltreatment, household dysfunction) is associated with a multiplicity of negative outcomes throughout the life course. Consequently, increasing interest is being paid to the application of routine enquiry for ACEs to enable identification and direct interventions to mitigate their harms. OBJECTIVE: To explore the evidence base for retrospective routine enquiry in adults for ACEs, including feasibility and acceptability amongst practitioners, service user acceptability and outcomes from implementation. METHODS: A scoping review of the literature was conducted, drawing upon three databases (CINAHL, MEDLINE, PsycINFO) and manual searching and citation tracking. Searches included studies published from 1997 until end of April 2018 examining enquiry into ACEs, or the feasibility/acceptability of such enquiry across any setting. All included studies presented empirical findings, with studies focusing on screening for current adversities excluded. RESULTS: Searches retrieved 380 articles, of which 15 met the eligibility criteria. A narrative approach to synthesize the data was utilized. Four studies examined practitioner feasibility and/or acceptability of enquiry, three reported service user acceptability and six studies implemented routine ACE enquiry (not mutually exclusive categories). Further, eight studies explored current practice and practitioner attitudes towards ACE enquiry. CONCLUSIONS: Limited literature was found providing evidence for outcomes from enquiry. No studies examined impacts on service user health or service utilization. Few studies explored feasibility or acceptability to inform the application of routine ACE enquiry. The implementation of routine ACE enquiry therefore needs careful consideration. Focus should remain on evaluating developing models of ACE enquiry to advance understanding of its impact.