An investment case analysis for the prevention and treatment of adolescent mental disorders and suicide in England.

BACKGROUND: Adolescent mental health (AMH) needs in England have increased dramatically and needs exceed treatment availability. This study undertook a comparative assessment of the health and economic return on investment (ROI) of interventions to prevent and treat mental disorders among adolescents (10-19 years) and examined intervention affordability and readiness. METHODS: Interventions were identified following a review of published and grey literature. A Markov model followed a simulated adolescent cohort to estimate implementation costs and health, education, and economic benefits. Intervention affordability was assessed, comparing annual cost per adolescent with NHS England per capita spending, and an expert panel assessed intervention readiness using a validated framework. RESULTS: Over 10- and 80-year horizons, interventions to treat mild anxiety and mild depression were most cost-effective, with the highest individual lifetime ROI (GBP 5822 GBP 1 and GBP 257: GBP 1). Preventing anxiety and depression was most affordable and 'implementation ready' and offered the highest health and economic benefits. A priority package (anxiety and depression prevention; mild anxiety and mild depression treatment) would avert 5 million disability-adjusted life-years (DALYS) and achieve an ROI of GBP 15: GBP 1 over 10 years or 11.5 million DALYs (ROI of GBP 55: GBP 1) over 80 years. CONCLUSION: The economic benefits from preventing and treating common adolescent mental disorders equivalent to 25% of NHS England's annual spending in 2021 over 10 years and 91% over 80 years. Preventing and early treatment for anxiety and depression had the highest ROIs and strong implementation readiness.

Modelo sinérgico de salud: una integración de la salutogénesis y el modelo de activos para la salud.

Se propone un "modelo sinérgico" para avanzar en la integración de elementos clave de la salutogénesis y el modelo de activos para la salud, utilizando como marco para esta articulación la teoría bioecológica de Bronfenbrenner. El sentido de coherencia es clave para facilitar la transformación de recursos potenciales en activos disponibles, produciendo un desarrollo positivo de la salud. El modelo sinérgico puede aportar a la contextualización de las ideas en políticas y prácticas de salud pública, fortaleciendo la dimensión salud-bienestar y contribuyendo al desarrollo de modelos de salud más integrados y colectivos.

Characterizing asset-based studies in public health: development of a framework.

Asset-based approaches are becoming more common within public health interventions; however, due to variations in terminology, it can be difficult to identify asset-based approaches. The study aimed to develop and test a framework that could distinguish between asset-based and deficit-based community studies, whilst acknowledging there is a continuum of approaches. Literature about asset-based and deficit-based approaches were reviewed and a framework was developed based on the Theory of Change model. A scoring system was developed for each of the five elements in the framework based on this model. Measurement of community engagement was built in, and a way of capturing how much the study involved an asset approach. The framework was tested on 13 studies examining community-based interventions to investigate whether it could characterize asset-based versus deficit-based studies. The framework demonstrated how much the principles underpinning asset-based approaches were present and distinguished between studies where the approach was deficit-based to those that had some elements of an asset-based approach. This framework is useful for researchers and policymakers when determining how much of an intervention is asset-based and identifying which elements of asset-based approaches lead to an intervention working.

Deficit-based approaches are a common approach to addressing public health issues within a community and involve identifying a health problem or need and finding a way to solve these. However, asset-based approaches, those that involve the community using its assets, or strengths, to enable community members to have more control over their health and wellbeing, are increasingly common. The terminology used to describe these methods varies greatly so it can be difficult to identify whether an approach is more deficit-based or asset-based. To address this a framework was developed to identify and score elements of asset-based studies. We did this by reviewing academic information describing asset-based approaches and built into this a scoring system. This framework was used to assess and measure the degree to which 13 community-based studies took an asset-based approach. The framework was able to identify studies which were more asset-based in their approach compared to those which were more deficit-focused, acknowledging that some studies may have elements of each approach. This framework will be useful for people working in health policy and research who want a resource to help identify asset-based approaches in practice and which aspects of the approach were important for its success in the community.

Common health assets protocol: a mixed-methods, realist evaluation and economic appraisal of how community-led organisations (CLOs) impact on the health and well-being of people living in deprived areas.

INTRODUCTION: This research investigates how community-led organisations' (CLOs') use of assets-based approaches improves health and well-being, and how that might be different in different contexts. Assets-based approaches involve 'doing with' rather than 'doing to' and bring people in communities together to achieve positive change using their own knowledge, skills and experience. Some studies have shown that such approaches can have a positive effect on health and well-being. However, research is limited, and we know little about which approaches lead to which outcomes and how different contexts might affect success. METHODS AND ANALYSIS: Using a realist approach, we will work with 15 CLOs based in disadvantaged communities in England, Scotland and Northern Ireland. A realist synthesis of review papers, and a policy analysis in different contexts, precedes qualitative interviews and workshops with stakeholders, to find out how CLOs' programmes work and identify existing data. We will explore participants' experiences through: a Q methodology study; participatory photography workshops; qualitative interviews and measure outcomes using a longitudinal survey, with 225 CLO participants, to assess impact for people who connect with the CLOs. An economic analysis will estimate costs and benefits to participants, for different contexts and mechanisms. A 'Lived Experience Panel' of people connected with our CLOs as participants or volunteers, will ensure the appropriateness of the research, interpretation and reporting of findings. ETHICS AND DISSEMINATION: This project, research tools and consent processes have been approved by the Glasgow Caledonian University School of Health and Life Sciences Ethics Committee, and affirmed by Ethics Committees at Bournemouth University, Queen's University Belfast and the University of East London. Common Health Assets does not involve any National Health Service sites, staff or patients.Findings will be presented through social media, project website, blogs, policy briefings, journal articles, conferences and visually in short digital stories, and photographic exhibitions.

School Closures During Social Lockdown and Mental Health, Health Behaviors, and Well-being Among Children and Adolescents During the First COVID-19 Wave: A Systematic Review.

IMPORTANCE: School closures as part of broader social lockdown measures during the COVID-19 pandemic may be associated with the health and well-being of children and adolescents. OBJECTIVE: To review published reports on the association of school closures during broader social lockdown with mental health, health behaviors, and well-being in children and adolescents aged 0 to 19 years, excluding associations with transmission of infection. EVIDENCE REVIEW: Eleven databases were searched from inception to September 2020, and machine learning was applied for screening articles. A total of 16 817 records were screened, 151 were reviewed in full text, and 36 studies were included. Quality assessment was tailored to study type. A narrative synthesis of results was undertaken because data did not allow meta-analysis. FINDINGS: A total of 36 studies from 11 countries were identified, involving a total of 79 781 children and adolescents and 18 028 parents, which occurred during the first wave of the COVID-19 pandemic (February to July 2020). All evaluated school closure as part of broader social lockdown during the first COVID-19 wave, and the duration of school closure ranged from 1 week to 3 months. Of those, 9 (25%) were longitudinal pre-post studies, 5 (14%) were cohort, 21 (58%) were cross-sectional, and 1 (3%) was a modeling study. Thirteen studies (36%) were high quality, 17 (47%) were medium quality, and 6 (17%) were low quality. Twenty-three studies (64%) were published, 8 (22%) were online reports, and 5 (14%) were preprints. Twenty-five studies (69%) concerning mental health identified associations across emotional, behavioral, and restlessness/inattention problems; 18% to 60% of children and adolescents scored above risk thresholds for distress, particularly anxiety and depressive symptoms, and 2 studies reported no significant association with suicide. Three studies reported that child protection referrals were lower than expected number of referrals originating in schools. Three studies suggested higher screen time usage, 2 studies reported greater social media use, and 6 studies reported lower physical activity. Studies on sleep (10 studies) and diet (5 studies) provided inconclusive evidence on harms. CONCLUSIONS AND RELEVANCE: In this narrative synthesis of reports from the first wave of the COVID-19 pandemic, studies of short-term school closures as part of social lockdown measures reported adverse mental health symptoms and health behaviors among children and adolescents. Associations between school closure and health outcomes and behaviors could not be separated from broader lockdown measures.

'A synergy model of health': an integration of salutogenesis and the health assets model.

This article proposes to advance the connections between salutogenic theory and assets models for health improvement. There is a need to integrate their use in public health and health promotion so that their respective potentials can be fully developed. This requires their synergies to be made more explicit so that a more coherent approach can be taken to their utilization. A mechanism is therefore needed that helps to raise awareness of them and their value as a resource together. Bronfenbrenner's bioecological theory provides one framework that can support better integration of salutogenesis with the applied nature of assets-based models. This paper proposes a new 'synergy model for health' that integrates key concepts associated with salutogenic theory-generalized and specific resistance resources (GRRs/SRRs) and generalized and specific resistance deficits and the sense of coherence (SOC). In doing so, it highlights those GRRs and SRRs which are assets that, either individually or collectively, help to develop a stronger SOC. Higher levels of SOC can then support the transformations of potential resources into available assets (that people can understand, manage and make sense of), capable of producing positive health development. The proposed 'Synergy model of health' aims to contribute to a deeper theoretical understanding of health and development through the integration of the key elements of both salutogenesis and assets models. This can facilitate a better contextualization of the ideas into public health policy and practice by making the salutogenic theory more action-oriented and the assets model more theoretical.

Advancing knowledge on social capital for young people's mental health.

Inequalities in young people's mental health have been documented according to social class but less is known about determinants that can buffer or mediate the relationship. Social capital has the potential to contribute to alleviating observed health inequalities. However, clarity about how it can be understood and measured in relation to mental health among younger populations remains inconsistent. This scoping review examined published literature to investigate how social capital has been researched for young people's mental health. An established framework was used to guide the methodology. Studies were included: on age (10-19 years); publication year (since 2000); language (English). Only studies using social capital as a central theme were included. No restriction was placed on mental health outcomes. Nine bibliographic databases were interrogated. Articles (1541) were screened, 793 retained for analysis and 73 articles were included. Most studies were conducted in North America and Europe. Twenty per cent provided insights into how social capital should be described in relation to young people. A majority of the studies provided links between varying social capital indicators and a range of mental health outcomes (70%), however such evidence was associational. Only few studies inferred the causal direction between social capital and health (10%) and there were no dedicated studies on measurement. Findings suggest that literature on social capital and young people's mental health has grown but continues to be variously described and measured. It requires better utilization of existing knowledge and new research to improve its application in practice.

A bio-ecological framing of evidence on the determinants of adolescent mental health - A scoping review of the international Health Behaviour in School-Aged Children (HBSC) study 1983-2020.

This paper extracts, organises and summarises findings on adolescent mental health from a major international population study of young people using a scoping review methodology and applying a bio-ecological framework. Population data has been collected from more than 1.5 million adolescents over 37 years by the Health Behaviour in School-Aged Children: WHO Cross-National (HBSC) Study. The paper reviews the contribution that this long standing study has made to our understanding of the individual, developmental, social, economic, cultural determinants of adolescent mental health by organising the findings of 104 empirical papers that met inclusion criteria, into individual, microsystem, mesosystem and macrosystem levels of the framework. Of these selected papers, 68 were based on national data and the other 36 were based on international data, from varying numbers of countries. Each paper was allocated to a system level in the bio-ecological framework according to the level of its primary focus. The majority (51 papers) investigate individual level determinants. A further 28 concentrate primarily on the microsystem level, 6 on the mesosystem level, and 29 on the macrosystem level. The paper identifies where there is evidence on the determinants of mental health, summarises what we have learned, and highlights research gaps. Implications for the future development of this population health study are discussed in terms of how it may continue to illuminate our understanding of adolescent mental health in a changing world and where new directions are required.

Public health programmes to promote mental health in young people: a systematic integrative review protocol.

INTRODUCTION: In light of the ever-growing mental health disease burden among young people worldwide, we aim to systematically review the global literature to identify the public health programmes targeted at promoting mental health and well-being in young people, the reported/anticipated mental health-related outcomes of the implemented public health programmes and the reported facilitators and barriers in relation to the implementation of those public health programmes. METHODS AND ANALYSIS: A comprehensive literature search will be carried out in the following electronic bibliographic databases: MEDLINE, EMBASE, PsycINFO, Scopus, ASSIA, Web of Science, Global Health, AMED, Health Source and The Cochrane Library. Further, a manual search of the reference lists of eligible studies and reviews will be carried out. The search strategy will include combinations of three key blocks of terms, namely: 'young people', 'mental health' and 'public health programme', using database-specific subject headings and text words. Two reviewers will independently screen, assess data quality and extract data for synthesis. Disagreements at any stage will be resolved by consensus with the involvement of a third reviewer. Given the anticipated methodological pluralism of the potential eligible studies, we will provide a narrative synthesis of the findings on public health programmes aimed at promoting the mental health and well-being of young people according to identified thematic areas. Furthermore, a narrative synthesis of the reported facilitators and barriers in relation to the implementation of public health programmes will be provided. ETHICS AND DISSEMINATION: Given that the review findings will be focused on understanding the breadth and depth of the global research into public health programmes to promote mental health in young people with a particular emphasis on the facilitators and barriers of programmatic implementation, the findings will be of great value to inform future interventions, programmes and approaches to promote mental health and well-being of young people worldwide. PROSPERO REGISTRATION NUMBER: CRD42018099551.

Knowledge and attitudes of adolescents to e-cigarettes: an international prospective study.

PURPOSE: The aim of the study was to assess the familiarity of adolescents with e-cigarettes. We performed a survey to investigate the frequency of their contact with e-cigarettes, beliefs about this sort of smoking (vaping), and their real knowledge of its effects. METHODS: The survey was carried out among 1600 high school students in the USA, Israel, Ukraine and Australia. The questionnaire comprised three parts, each with five questions. The first part was designed to assess the frequency of contact with the phenomenon. The second part assessed misconceptions and opinions concerning vaping. The third part questioned the participants' real knowledge of the subject. RESULTS: Out of a maximum score of 5, the average score of 4.25 for Part 1 indicated that the participants had frequent contact with e-cigarettes. The score of 3.65 for Part 2 showed that adolescents have both right and wrong beliefs on the subject. Part 3 was completed by 1224 participants (76.5%) while 376 (23.5%) reported a lack of any specific knowledge about vaping. The average score of 3.33 demonstrated that adolescents who completed Part 3 of the survey have incomplete knowledge about e-cigarettes. For the whole cohort of 1600 participants, the average score was 2.80. No significant sex differences were detected. The Ukranian participants had poor knowledge about the dangers of vaping in comparison with the participants in the USA and Australia (p = 0.03). CONCLUSION: While the contact of adolescents with e-cigarettes users is extensive, their actual knowledge remains inadequate. Various school-based smoking risk campaigns face a necessity for further adjustments and improvements.

Well-being profiles in adolescence: psychometric properties and latent profile analysis of the mental health continuum model - a methodological study.

BACKGROUND: The Adolescent Mental Health Continuum Short Form (MHC-SF) is a psychometrically valid tool to evaluate the domains of subjective well-being, but there is a lack of investigations which could distinguish subgroups with distinct subjective well-being profiles based on this measurement. Therefore, after testing the competing measurement models of the MHC-SF, our main aim was to identify subjective well-being profiles in a large adolescent sample. METHODS: On a representative Hungarian adolescent sample (N = 1572; 51% girl; mean age was 15.39, SD = 2.26) confirmatory factor analyses (CFA) and exploratory structural equation modeling (ESEM) were used to test the factor stucture of the Adolescent MHC-SF. In addition, gender invariance of the best fitting model was also tested. Latent Profile Analyses (LPA) were conducted to reveal distinct subgroups and these profiles were then compared. RESULTS: Results support the bifactor model of MHC-SF: the general and specific well-being factors which were invariant across gender. LPA yielded four subgroups, three of them have been theoretically hypothesized in previous works (i.e. flourishing, moderate mental health, languishing), but an emotionally vulnerable subgroup also emerged. Compared to the languishing group, this new subgroup demonstrated higher scores on prosocial behaviour, but had comparable level of loneliness and internalizing symptoms. CONCLUSIONS: Our results suggest that the MHC-SF is a reliable and valid instrument for assessing overall well-being and its components. In addition, the identification of young people to be at risk for low mental health may help us to tailor mental health promotion programs to their special needs.

The practitioners' perspective on the upside and downside of applying social capital concept in therapeutic settings.

Social capital, and more particularly the social networks that define its existence, is said to benefit health and well-being. In individuals recovering from alcohol and drug addiction, social capital accruing from social networks support treatment, recovery and maintenance. Therefore, the concept of social capital is important for public health practitioners working in recovery interventions. This qualitative study seeks to explore what practitioners perceive as the importance of social capital and how they apply the concept in interventions to support individuals recovering from drug and alcohol addiction. Eight public health practitioners involved in drug and substance abuse interventions in West Yorkshire, England, were interviewed. The results of the interview were then deductively coded using two priori themes of perceived impact of social capital on health outcomes and application of social capital theory in recovery interventions. The findings reveal that practitioners understand the impact of social capital as the effects of social networks on recovery and apply the concept in their interventions. However, the nature of interventions created based on similarities in condition (alcohol and substance addiction) and intended outcome (recovery) create bonding social capital with mixed outcomes. This paper argues that the wider benefits to service users are unintentionally inhibited by the overwhelming downsides of bonding social capital. For instance, closed support groups comprised of individuals with high similarities further exclude the already socioeconomically deprived service users from integrating and accessing resources outside their groups.

Measuring Psychological Inflexibility in Children and Adolescents: Evaluating the Avoidance and Fusion Questionnaire for Youth.

The Avoidance and Fusion Questionnaire for Youth (AFQ-Y8) was developed to measure psychological inflexibility. Although the questionnaire is a well-known tool in clinical practice, its psychometric properties have not been widely investigated in the target population of children and adolescents. The purpose of this study was to investigate the factor structure and validity of the AFQ-Y8 (N = 1,572, mean age 15.39 years, girls 51%) on a Hungarian sample. We also tested the invariance of the measurement model across two age groups (11-14 and 15-20 years old). Results confirmed the single-factor structure of the AFQ-Y8. Psychological inflexibility was also found to be positively related to emotional instability, externalizing, and internalizing problems. Furthermore, psychological inflexibility explained the variance of life satisfaction when personality dimensions, emotional, and behavioral problems were accounted for. Measurement invariance across age groups was partially supported. These results suggest that the AFQ-Y8 is a reliable and valid instrument for assessing psychological inflexibility in children and adolescents.

Callous-unemotional traits and the attentional bias towards emotional stimuli: Testing the moderating role of emotional and behavioural problems among high-risk adolescents.

Former studies demonstrated that antisocial youth with callous-unemotional (CU) traits are impaired in the processing of negative emotional stimuli. The aim of the current study was to explore the moderating role of different behavioural (i.e. conduct problems, hyperactivity-inattention) and emotional problems (i.e. internalizing symptoms) in the relationship between CU traits and attentional bias towards emotional stimuli. Besides using self-report measures, attentional bias was tested by an affective dot-probe task in a high-risk sample of 102 adolescent boys (M age = 16.34 years; SD = 1.32). CU traits were related to reduced attention to emotionally distressing pictures. Furthermore, conduct problems significantly moderated the relationship between CU traits and attention to distress cues. These findings highlight the importance of considering potential moderators to the well-established link between CU traits and deficits in response to negative emotional cues.

Health assets in a global context: a systematic review of the literature.

OBJECTIVE: To provide an up-to-date overview of health assets in a global context both from a theoretical perspective and its practical applications to address health inequalities and achieve sustainable health. DESIGN: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: A comprehensive search, including 10 electronic bibliographic databases and hand searches, was undertaken to capture the wide range of terms associated with 'health assets' and 'asset-based approaches to health'. ELIGIBILITY CRITERIA: Any peer-reviewed published and grey literature in English related to 'health assets' or 'assets' in a 'health' context was included without any date, country or study design restrictions and the quality of evidence was appraised according to the Oxford Level of Evidence. OUTCOMES: A broad consideration of all outcome measures including clinical outcomes, patient-level, community-level and population-level impacts and costs, was adopted. RESULTS: 478 publications were included. Health assets were researched in 40 countries, predominantly in the West such as the USA and the UK. A number of broad health assets were identified including community and individual assets. Even though research was conducted in a number of different settings, most occurred in the community, clinical, care or educational settings. A wide variety of interventions and approaches were implemented, most commonly related to education and/or training, asset mapping or asset approaches. CONCLUSIONS: Globally, authors most often referred to general 'health assets', 'assets' or some form of 'community asset' in relation to health. Overall, the idea of health assets is framed within a positive paradigm focusing on health creation rather than curative approaches. The sustained credibility of the global 'health assets' literature depends on future research on definitional, theoretical and evaluative issues in order to convince policy-makers and service commissioners of its necessity and added value to the traditional deficit approach.

Into the realm of social capital for adolescents: A latent profile analysis.

BACKGROUND: Recent reports of increasing prevalence of frequent health complaints and mental health problems among adolescents call for directing more attention on determinants of adolescent health. The relationship between health and social capital has gained increased attention since the early 2000's and research at review level confirms the importance of social capital for health outcomes, despite methodological heterogeneity. The aim of this study was to identify distinct profiles of family, school and peer social capital in a nationally representative sample of adolescents and to explore health outcomes in those profiles. METHOD: Cross-sectional data from the Swedish Health Behaviour of School-aged Children 2013/14 was used for this study. The analytical sample consisted of 7,804 adolescents aged 11-, 13- and 15-years. Items representing sense of belonging and emotional support were assessed in three contexts; family, school and among peers. Latent profile analyses (LPA) were run to determine social capital profiles. Health outcomes included frequent health complaints and life satisfaction, while socioeconomic status and genders were included as predictors. RESULTS: The results show that five distinct profiles best represent the data for 11- and 15-year olds, while a four-profile model was optimal for 13-year olds. Some profiles were recurrent between age groups but unique profiles were also found. Health outcomes were significantly different between profiles depending on levels of social capital in the different contexts. CONCLUSIONS: This study provides novel insight into how social capital co-occurs among adolescents within the contexts of family, school and peers and how this translates into differences in health outcomes. The national representativeness of the sample increases the implications of the results and contributes to meaningful insights that help explain the interactions of social capital in multiple contexts, complementing what is previously known about the relationship with adolescent health.

Optimism as a Candidate Health Asset: Exploring Its Links With Adolescent Quality of Life in Sweden.

This study aims to understand the role that optimism could play in the context of a health asset approach to promote adolescent health-related quality of life (HRQOL). Adolescents (n = 948), between 11 and 16 years old from a medium-sized rural town in Sweden, answered questionnaires measuring optimism, pessimism, and HRQOL. The findings indicate a significant decrease in optimism and a significant increase in pessimism between early and midadolescence. The study has allowed us to present associational evidence of the links between optimism and HRQOL. This infers the potential of an optimistic orientation about the future to function as a health asset during adolescence and by implication may provide additional intervention tool in the planning of health promotion strategies.

Gender Invariance and Psychometric Properties of the Nonproductive Thoughts Questionnaire for Children.

Perseverative cognitions-rumination and worry-can contribute to mental and somatic health problems in adolescence. Girls usually report stronger rumination or worry than boys even in earlier years across the development age spectrum. Our aim was to test the gender invariance and psychometric properties of the Nonproductive Thoughts Questionnaire for Children (NPTQ-C). Study 1 involved 1,572 students (mean age = 15.39 years, SD = 2.26; 49% boy) recruited representatively from local schools. We applied confirmatory factor analysis (CFA) to test the measurement model of perseverative cognitions. The gender invariance of the measurement model and the convergent validity were analyzed as well with CFA with covariates model. The original one-factor structure of NPTQ-C was supported in our adolescent sample. Gender invariance was also confirmed. The NPTQ-C indicated high convergent validity: showing positive correlations with emotional instability and emotional symptoms. In Study 2 (385 students; mean age = 16.05; SD = 1.23; 34% boy), we tested the construct validity of NPTQ-C. The applied CFA with covariates model supported the construct validity. In summary, NPTQ-C proved to be a good instrument for measuring ruminative and worrying thoughts of adolescents, which reliably measures perseverative cognitions across genders.

Seatbelt use and risk of major injuries sustained by vehicle occupants during motor-vehicle crashes: a systematic review and meta-analysis of cohort studies.

BACKGROUND: In 2004, a World Health Report on road safety called for enforcement of measures such as seatbelt use, effective at minimizing morbidity and mortality caused by road traffic accidents. However, injuries caused by seatbelt use have also been described. Over a decade after publication of the World Health Report on road safety, this study sought to investigate the relationship between seatbelt use and major injuries in belted compared to unbelted passengers. METHODS: Cohort studies published in English language from 2005 to 2018 were retrieved from seven databases. Critical appraisal of studies was carried out using the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Pooled risk of major injuries was assessed using the random effects meta-analytic model. Heterogeneity was quantified using I-squared and Tau-squared statistics. Funnel plots and Egger's test were used to investigate publication bias. This review is registered in PROSPERO (CRD42015020309). RESULTS: Eleven studies, all carried out in developed countries were included. Overall, the risk of any major injury was significantly lower in belted passengers compared to unbelted passengers (RR 0.47; 95%CI, 0.29 to 0.80; I2 = 99.7; P = 0.000). When analysed by crash types, belt use significantly reduced the risk of any injury (RR 0.35; 95%CI, 0.24 to 0.52). Seatbelt use reduces the risk of facial injuries (RR = 0.56, 95% CI = 0.37 to 0.84), abdominal injuries (RR = 0.87; 95% CI = 0.78 to 0.98) and, spinal injuries (RR = 0.56, 95% CI = 0.37 to 0.84). However, we found no statistically significant difference in risk of head injuries (RR = 0.49; 95% CI = 0.22 to 1.08), neck injuries (RR = 0.69: 95%CI 0.07 to 6.44), thoracic injuries (RR 0.96, 95%CI, 0.74 to 1.24), upper limb injuries (RR = 1.05, 95%CI 0.83 to 1.34) and lower limb injuries (RR = 0.77, 95%CI 0.58 to 1.04) between belted and non-belted passengers. CONCLUSION: In sum, the risk of most major road traffic injuries is lower in seatbelt users. Findings were inconclusive regarding seatbelt use and susceptibility to thoracic, head and neck injuries during road traffic accidents. Awareness should be raised about the dangers of inadequate seatbelt use. Future research should aim to assess the effects of seatbelt use on major injuries by crash type.

Building school-based social capital through 'We Act - Together for Health' - a quasi-experimental study.

BACKGROUND: Social capital has been found to be positively associated with various health and well-being outcomes amongst children. Less is known about how social capital may be generated and specifically in relation to children in the school setting. Drawing on the social cohesion approach and the democratic health educational methodology IVAC (Investigation - Vision - Action - Change) the aim of this study was to examine the effect of the Health Promoting School intervention 'We Act - Together for Health' on children's cognitive social capital. METHOD: A quasi-experimental controlled pre- and post-intervention study design was conducted with 548 participants (mean age 11.7 years). Cognitive social capital was measured as: horizontal social capital (trust and support in pupils); vertical social capital (trust and support in teachers); and a sense of belonging in the school using questions derived from the Health Behaviour in School Children study. A series of multilevel ordinal logistic regression analyses was performed for each outcome to estimate the effect of the intervention. RESULT: The analyses showed no overall significant effect from the intervention on horizontal social capital or vertical social capital at the six-month follow-up. A negative effect was found on the sense of belonging in the school. Gender and grade appeared to be important for horizontal social capital, while grade was important for sense of belonging in the school. The results are discussed in relation to We Act's implementation process, our conceptual framework and methodological issues and can be used to direct future research in the field. CONCLUSION: The study finds that child participation in health education can affect the children's sense of belonging in the school, though without sufficient management support, this may have a negative effect. With low implementation fidelity regarding the Action and Change dimension of the intervention at both the school and class level, and with measurement issues regarding the concept of social capital, more research is needed to establish a firm conclusion on the importance of the children's active participation as a source for cognitive social capital creation in the school setting. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN85203017.