Intersectional discrimination and mental health inequalities: a qualitative study of young women's experiences in Scotland.

BACKGROUND: In 2021, Scotland became the first UK country to launch a Women's Health Plan. This policy signals increasing commitment to broader ambitions surrounding gender equality in health. Research shows a connection between discrimination and health, representing a contributor to health inequalities. There remains sparse evidence on how certain groups experience discrimination that could be useful for policymaking. This research set out to address this evidence gap through exploring how discrimination shapes young women's experiences of mental health and inequalities in Scotland. METHODS: We interviewed women aged 16-25 years (n=28), living in Scotland, UK, adopting an intersectional approach to recruitment and data analysis. We used a semi-structured topic guide to facilitate open discussion about discrimination and health. Transcripts were analysed by two researchers using Thematic Analysis and NVivo software. FINDINGS: We identified three themes that illuminate intersectional discrimination and the impact on mental health. The first outlines how experiences of discrimination in school, work and public spaces (and the anticipation of such) creates stress leading to mental health problems, particularly for participants from ethnic minority groups. The second highlights the lack of support for mental health, both at structural and interpersonal levels, which was viewed by young women as a form of intersectional discrimination, largely because of their gender and age. Finally, we developed a mid-level theory termed the 'chain of dismissal' that displays that for both physical or mental health symptoms, young women's concerns are immediately "written off" as anxiety-related and in turn a natural attribute of young women. These themes show that discrimination has the potential to amplify mental health problems for young women and is a likely contributor to health inequalities. CONCLUSIONS: Structural disadvantages such as racism intersect with gender and age to compound the experience of discrimination for marginalised young women. To improve mental health and reduce health inequalities for young women, multi-level approaches are needed, with strong consideration of how the structural and cultural landscape as well as assumptions made by healthcare professionals have critical implications for young women's health.

Community mobilisation approaches to preventing adolescent multiple risk behaviour: a realist review.

BACKGROUND: Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts. METHODS: This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory. FINDINGS: We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired. CONCLUSIONS: For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020205342.

A qualitative exploration of food portion size practices and awareness of food portion size guidance in first-time parents of one- to two-year-olds living in the UK.

BACKGROUND: Food portion size guidance resources aimed at parents of young children in the UK are freely available from a number of credible sources. However, little is known about whether parents are aware of, and use, any of these resources to guide their food portioning practices. OBJECTIVES: We aimed to explore the food portion size practices used by first-time parents living in the UK when feeding their one- to two-year-old child, and their awareness of and views on six food portion size guidance resources. METHODS: Participants were recruited via parent Facebook groups and online parent forums. Online 1-1 semi-structured interviews were conducted, during which parents were shown images of six food portion size guidance resources to facilitate discussion. Data was analysed in NVivo 11 using a Reflexive Thematic Analysis approach. RESULTS: Of the 27 participants, most were women (n = 25), white (n = 18), and educated to first degree level or higher (n = 24). First-time parents mostly relied on their own judgement and "instinct" to portion foods, based on their learned experience of how much their child ate on a day-to-day basis. This experience was used alongside physical indicators of food portion size, such as the size of children's dishware and food packaging. Most participants were unaware of any of the six food portion size guidance resources we showed them; only four had read any of the resources. Parents suggested they had previously sought advice about weaning from a range of sources (e.g. online, friends, community groups) but would be unlikely to seek out specific food portion size guidance. Parents suggested recommendations on food portion size should acknowledge and highlight parents' perception that "every child is different". CONCLUSIONS: Existing food portion size guidance resources for parents of young children in the UK are ineffective as they have poor reach and impact. We suggest parents should be involved in developing novel strategies to promote age-appropriate consumption and healthy weight gain in young children.

Use of Intersectionality Theory in Interventional Health Research in High-Income Countries: A Scoping Review.

BACKGROUND: Intersectionality theory posits that considering a single axis of inequality is limited and that considering (dis)advantage on multiple axes simultaneously is needed. The extent to which intersectionality has been used within interventional health research has not been systematically examined. This scoping review aimed to map out the use of intersectionality. It explores the use of intersectionality when designing and implementing public health interventions, or when analysing the impact of these interventions. METHODS: We undertook systematic searches of Medline and Scopus from inception through June 2021, with key search terms including "intersectionality", "interventions" and "public health". References were screened and those using intersectionality and primary data from high-income countries were included and relevant data synthesised. RESULTS: After screening 2108 studies, we included 12 studies. Six studies were qualitative and focused on alcohol and substance abuse (two studies), mental health (two studies), general health promotion (one study) and housing interventions (one study). The three quantitative studies examined mental health (two studies) and smoking cessation (one study), while the three mixed-method studies examined mental health (two studies) and sexual exploitation (one study). Intersectionality was used primarily to analyse intervention effects (eight studies), but also for intervention design (three studies), and one study used it for both design and analysis. Ethnicity and gender were the most commonly included axes of inequality (11 studies), followed by socio-economic position (10 studies). Four studies included consideration of LGBTQ+ and only one considered physical disability. Intersectional frameworks were used by studies to formulate specific questions and assess differences in outcomes by intersectional markers of identity. Analytical studies also recommended intersectionality approaches to improve future treatments and to structure interventions to focus on power and structural dynamics. CONCLUSIONS: Intersectionality theory is not yet commonly used in interventional health research, in either design or analysis. Conditions such as mental health have more studies using intersectionality, while studies considering LGBTQ+ and physical disability as axes of inequality are particularly sparse. The lack of studies in our review suggests that theoretical and methodological advancements need to be made in order to increase engagement with intersectionality in interventional health.

Individual-, family- and school-based interventions to prevent multiple risk behaviours relating to alcohol, tobacco and drug use in young people aged 8-25 years: a systematic review and meta-analysis.

BACKGROUND: Engagement in multiple substance use risk behaviours such as tobacco smoking, alcohol and drug use during adolescence can result in adverse health and social outcomes. The impact of interventions that address multiple substance use risk behaviours, and the differential impact of universal versus targeted approaches, is unclear given findings from systematic reviews have been mixed. Our objective was to assess effects of interventions targeting multiple substance use behaviours in adolescents. METHODS: Eight databases were searched to October 2019. Individual and cluster randomised controlled trials were included if they addressed two or more substance use behaviours in individuals aged 8-25 years. Data were pooled in random-effects meta-analyses, reported by intervention and setting. Quality of evidence was assessed using GRADE. Heterogeneity was assessed using between-study variance, τ2 and Ι2, and the p-value of between-study heterogeneity statistic Q. Sensitivity analyses were undertaken using the highest and lowest intra-cluster correlation coefficient (ICC). RESULTS: Of 66 included studies, most were universal (n=52) and school-based (n=41). We found moderate quality evidence that universal school-based interventions are likely to have little or no short-term benefit (up to 12 months) in relation to alcohol use (OR 0.94, 95% CI: 0.84, 1.04), tobacco use (OR 0.98, 95% CI: 0.83, 1.15), cannabis use (OR 1.06, 95% CI: 0.86, 1.31) and other illicit drug use (OR 1.09, 95% CI: 0.85, 1.39). For targeted school-level interventions, there was low quality evidence of no or a small short-term benefit: alcohol use (OR 0.90, 95% CI: 0.74-1.09), tobacco use (OR 0.86, 95% CI: 0.66, 1.11), cannabis use (OR 0.84, 95% CI: 0.66-1.07) and other illicit drug use (OR 0.79, 95% CI 0.62-1.02). There were too few family-level (n=4), individual-level (n=2) and combination level (n=5) studies to draw confident conclusions. Sensitivity analyses of ICC did not change results. CONCLUSIONS: There is low to moderate quality evidence that universal and targeted school-level interventions have no or a small beneficial effect for preventing substance use multiple risk behaviours in adolescents. Higher quality trials and study reporting would allow better evidence syntheses, which is needed given small benefit of universal interventions can have high public health benefit. TRIAL REGISTRATION: Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD011374. DOI: 10.1002/14651858.CD011374.

Preconception exposures and adverse pregnancy, birth and postpartum outcomes: Umbrella review of systematic reviews.

BACKGROUND: Preconception exposures have been associated with adverse pregnancy, birth and postpartum outcomes. However, the reports, statements and guidelines of national and international health organisations vary in what they recommend individuals should monitor, avoid, reduce or practise in the preconception period. OBJECTIVES: To synthesise and evaluate the evidence across systematic reviews for associations between exposures before conception and adverse pregnancy, birth and postpartum outcomes. DATA SOURCES: MEDLINE, Embase, Epistemonikos (to May 2020) and reference lists of included reviews, without language or date restrictions. STUDY SELECTION, DATA EXTRACTION AND SYNTHESIS: Systematic literature reviews of observational and/or interventional studies reporting associations between preconception exposures in women and/or men of reproductive age and pregnancy, birth or postpartum health outcomes were included. The methodological quality of reviews and the certainty of the evidence underlying each exposure-outcome association were assessed using AMSTAR 2 and the GRADE approach. RESULTS: We identified 53 eligible reviews reporting 205 unique exposure-outcome associations. Methodological quality was generally low with only two reviews rated as 'high' quality and two as 'moderate'. We found high-certainty, randomised trial evidence that maternal folate supplementation reduces the risk of neural tube defects and anomaly-related terminations. Moderate-certainty, observational evidence was found that maternal physical activity is associated with reduced risk of pre-eclampsia and gestational diabetes, and that paternal age of ≥40 years and maternal body mass index (BMI) and interpregnancy weight gain are associated with increased risk of various adverse pregnancy and birth outcomes. Low- and very low-certainty evidence was found for other associations. CONCLUSIONS: Clinicians and policymakers can be confident that maternal folate supplementation should be encouraged during the preconception period. There is moderate certainty in the evidence base that maternal physical activity, BMI and interpregnancy weight gain and advanced paternal age are important preconception considerations. High-quality research is required to better understand other exposure-outcome associations.

Is adolescent multiple risk behaviour associated with reduced socioeconomic status in young adulthood and do those with low socioeconomic backgrounds experience greater negative impact? Findings from two UK birth cohort studies.

BACKGROUND: Adolescent multiple risk behaviour (MRB) is associated with negative outcomes such as police arrests, unemployment and premature mortality and morbidity. What is unknown is whether MRB is associated with socioeconomic status (SES) in adulthood. We test whether adolescent MRB is associated with socioeconomic status (SES) in young adulthood and whether it is moderated by early life SES variables. METHODS: Prospective cohort studies; British Cohort Study 1970 (BCS70) and Avon Longitudinal Study of Parents and Children (ALSPAC), born in 1991-1992, were used and two comparable MRB variables were derived. Logistic regression was used to determine the association between MRB and young adult SES. The moderating effect of three early life SES variables was assessed using logistic regression models with and without interaction parameters. Evidence to support the presence of moderation was determined by likelihood ratio tests ≤p = 0.05. Multiple imputation was used to account for missing data. RESULTS: Adolescents had a median of two risk behaviours in BCS70 and three in ALSPAC. Adolescent MRB was negatively associated with young adult SES (university degree attainment) in BCS70 (OR 0.81, 95% CI: 0.76, 0.86) and ALSPAC (OR 0.85, 95% CI: 0.82, 0.88). There was a dose response relationship, with each additional risk behaviour resulting in reduced odds of university degree attainment. MRB was associated occupational status at age 34 in BCS70 (OR 0.86 95% CI: 0.82, 0.90). In BCS70, there was evidence that maternal education (p = 0.03), parental occupational status (p = 0.009) and household income (p = 0.03) moderated the effect of adolescent MRB on young adult SES in that the negative effect of MRB is stronger for those with low socioeconomic backgrounds. No evidence of moderation was found in the ALSPAC cohort. CONCLUSIONS: Adolescence appears to be a critical time in the life course to address risk behaviours, due to the likelihood that behaviours established here may have effects in adulthood. Intervening on adolescent MRB could improve later SES outcomes and thus affect health outcomes later in life. Evidence for a moderation effect in the BCS70 but not ALSPAC suggests that more detailed measures should be investigated to capture the nuance of contemporary young adult SES.

Community mobilisation approaches to preventing and reducing adolescent multiple risk behaviour: a realist review protocol.

BACKGROUND: Adolescent multiple risk behaviour (MRB) continues to be a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, rather than targeting the wider environmental or structural context. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. Despite this, there are gaps in the current literature, theory and implementation that would benefit from a realist approach due to the suitability of this methodology to analysing complex interventions. The objective of this study is to understand 'how, why, for whom and in what circumstances and time periods' do community mobilisation interventions work to prevent and/or reduce adolescent multiple risk behaviour. METHODS: This is a protocol for a realist review. The review will use a six-stage iterative process, guided by the RAMESES framework. We will systematically search PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies will be screened for relevance to the programme theory and included based on a priori eligibility criteria including (1) reporting a community mobilisation intervention (2) targeting two health risk behaviors (3) for adolescent populations. Two independent reviewers will select, screen and extract data related to the program theory from all relevant sources. A realist logic of analysis will be used to identify all context-mechanism-outcome configurations that contribute to our programme theory. The findings will be synthesised to produce a refined programme theory model. DISCUSSION: The goal of this realist review is to identify and refine a programme theory for community mobilisation approaches to the prevention and/or reduction of adolescent multiple risk behaviour. Our aim is that the findings surrounding the programme theory refinement can be used to develop and implement adolescent multiple risk behaviour interventions and maintain collaboration between local policy makers, researchers and community members. SYSTEMATIC REVIEW REGISTRATION: This realist review is registered on the PROSPERO database (registration number: CRD42020205342).

Understanding adolescent health risk behaviour and socioeconomic position: A grounded theory study of UK young adults.

Health risk behaviours such as tobacco smoking, excessive alcohol consumption, drug use, unhealthy diet and unprotected sexual intercourse contribute to the global burden of non-communicable diseases and are often initiated in adolescence. An individualistic focus on 'health risk behaviours' has resulted in behaviour change strategies that are potentially ineffective and increase inequalities. We conducted a grounded theory study of 25 young adults to increase the limited qualitative evidence base surrounding young people, health risk behaviours and socioeconomic inequalities. We found that health risk behaviours were perceived as class markers, manifesting as class stigma, leading some participants from lower socioeconomic backgrounds to employ strategies to avoid such behaviours. Peers and family were core constructs for understanding the relationship between health risk behaviours and socioeconomic life trajectories. However, individualism and choice were consistently expressed as the overriding narrative for understanding health risk behaviour and socioeconomic position during the transition to adulthood. The use of 'personal responsibility' discourse by young adults, we argue, highlights the need for a public health focus on achieving structural changes as opposed to individualised approaches to avoid reinforcing neoliberal ideologies that serve to marginalise and maintain social inequalities.

Qualitative Evaluation of Web-Based Digital Intervention to Prevent and Reduce Excessive Alcohol Use and Harm Among Young People Aged 14-15 Years: A "Think-Aloud" Study.

BACKGROUND: In the United Kingdom, despite some downward trends in alcohol use among young people, over one-fifth of young people reported excessive alcohol use in the past month, which is associated with short- and long-term harm to health. Digital interventions to reduce alcohol use, such as websites, among young people present an appealing and cost-effective mode of intervention that can be integrated into the education system. However, relatively few school-based digital alcohol-focused interventions have been developed and evaluated for young people in the United Kingdom. OBJECTIVE: This study aims to develop a novel web-based intervention, Rethink Alcohol, to prevent and reduce excessive alcohol use and related harm among young people aged between 14 and 15 years, and explore the views of young people, teachers, and youth workers in relation to the content, design, and usability of the intervention. METHODS: Intervention development followed the person-based approach, using theories of social norms and social influence. Qualitative "Think-Aloud" interviews, either one-to-one or paired, were conducted while participants perused and worked through the web-based intervention, talking aloud. Participants included 20 young people (12 female, 8 male), 5 youth workers (4 female, 1 male), 3 teachers (2 male, 1 female), and 1 (male) clinical professional, recruited via youth groups and professional networks. Interviews were audio recorded, transcribed verbatim, and analyzed thematically. RESULTS: The prototype web-based intervention included normative feedback, information, a quiz, interactive activities, and scenarios. On a rating scale of impressions from poor (1) to excellent (5), participants gave an average score of 3.6/5. A total of 5 themes were identified: content, credibility of the website, making the website easy to understand, design and navigation, and suitability for the audience. These themes reflected views that the content was interesting, credible, informative, and embodied a neutral and nonjudgmental tone, but stronger messaging was needed regarding social pressures and short-term risks regarding safety and risk behavior alongside clarity around pathways of risk; credibility and trustworthiness of information were critical features, determined in part, by the professionalism of design and referencing of sources of information provided; and messages should be succinct and come to life through design and interactive features. CONCLUSIONS: Together, the data illustrated the importance and challenge of communicating nuanced alcohol-focused public health messages to young people in concise, clear, nonjudgmental, and appealing ways. Young people report interest in clear, credible, neutral, and interactive messages regarding social pressures and short-term risks of alcohol use via a web-based intervention. There is scope for optimization and feasibility testing of the Rethink Alcohol intervention.

Cross-sectional analysis of physical activity in 2-4-year-olds in England with paediatric quality of life and family expenditure on physical activity.

BACKGROUND: Many children do not meet the recommended level of daily physical activity, even with the widely acknowledged health benefits associated with being physically active. There is a need to establish factors related to physical activity in children so that public health interventions may be appropriately designed. We investigated the association between Pediatric Quality of Life Inventory (PedsQL), family expenditure on physical activity and objectively measured daily physical activity in 2-4-year-old children. METHODS: Cross-sectional study with a sample of 81 UK preschool children taking part in the NAPSACC UK feasibility randomized controlled trial. Descriptive statistics are presented. We undertook Student t-tests to establish differences in physical activity by gender, age, parental education and nursery versus non-nursery days. Mixed effects linear regressions were used to model the association between minutes spent physically activity, minutes spent in moderate-to-vigorous (MVPA) physical activity and PedsQL scores (physical and psychosocial) and family expenditure on physical activity. RESULTS: Most children (88.9%) did not engage in the recommended 180 min daily physical activity. There was mean (SD) of 141.9 (33.1) daily minutes of physically activity and 22.2 min per day (SD = 9.9) of MVPA. Boys and older children were more physically active. Children were more active on nursery days. There was no difference in physical activity by parental education. Half of the sample parents (50.6%) spent less than £9.00 weekly on their pre-schooler's physical activity. Children within the highest tertile of PedsQL physical functioning scores had higher levels of MVPA (3.6, 95% CI: - 1.3-8.4, p-value 0.15), although confidence intervals crossed the null in the adjusted model. We found no evidence of an association between positive PedsQL psychosocial scores, or higher parental expenditure on physical activity, with the physical activity variables. CONCLUSIONS: Children in this sample were not meeting the recommended 180 min of daily physical activity. The 2-4-year-olds were most active on nursery days. There is no evidence of an association between better PedsQL physical scores and higher levels of MVPA. There was no evidence of an association between expenditure on physical activity and time spent physically active. Further examination in larger representative datasets is needed.

Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence.

BACKGROUND: Multiple risk behaviour (MRB) refers to two or more risk behaviours such as smoking, drinking alcohol, poor diet and unsafe sex. Such behaviours are known to co-occur in adolescence. It is unknown whether MRB interventions are equally effective for young people of low and high socioeconomic status (SES). There is a need to examine these effects to determine whether MRB interventions have the potential to narrow or widen inequalities. METHODS: Two Cochrane systematic reviews that examined interventions to reduce adolescent MRB were screened to identify universal interventions that reported SES. Study authors were contacted, and outcome data stratified by SES and intervention status were requested. Risk behaviour outcomes alcohol use, smoking, drug use, unsafe sex, overweight/obesity, sedentarism, peer violence and dating violence were examined in random effects meta-analyses and subgroup analyses conducted to explore differences between high SES and low SES adolescents. RESULTS: Of 49 studies reporting universal interventions, only 16 also reported having measured SES. Of these 16 studies, four study authors provided data sufficient for subgroup analysis. There was no evidence of subgroup differences for any of the outcomes. For alcohol use, the direction of effect was the same for both the high SES group (RR 1.26, 95% CI: 0.96, 1.65, p = 0.09) and low SES group (RR 1.14, 95% CI: 0.98, 1.32, p = 0.08). The direction of effect was different for smoking behaviour in favour of the low SES group (RR 0.83, 95% CI: 0.66, 1.03, p = 0.09) versus the high SES group (RR 1.16, 95% CI: 0.82, 1.63, p = 0.39). For drug use, the direction of effect was the same for both the high SES group (RR 1.29, 95% CI: 0.97, 1.73, p = 0.08) and the low SES group (RR 1.28, 95% CI: 0.84, 1.96, p = 0.25). CONCLUSIONS: The majority of studies identified did not report having measured SES. There was no evidence of subgroup difference for all outcomes analysed among the four included studies. There is a need for routine reporting of demographic information within studies so that stronger evidence of effect by SES can be demonstrated and that interventions can be evaluated for their impact on health inequalities.