Characteristics of paediatric frequent presenters at emergency departments: A whole-of-population study.

AIM: To quantify the frequency of emergency department (ED) presentations and profile the socio-demographic, health and presentation characteristics of paediatric ED frequent presenters. METHODS: A population-based data linkage study of 55 921 children in the South Australian Early Childhood Data Project aged 0-12 years with 100 976 presentations to public hospital EDs in South Australia. For each child, the total number of recurrent ED presentations during a 364-day period post-index presentation was calculated. Frequent presenters were children who experienced ≥4 recurrent ED presentations. We determined the socio-demographic, health and presentation characteristics by number of recurrent presentations. RESULTS: Children with ≥4 recurrent presentations (4.4%) accounted for 15.4% of all paediatric ED presentations and 22.5% of subsequent admissions to hospital during the 12-month study period. Compared to children with no recurrent ED presentation, frequent presenters had higher proportions of socio-economic and health disadvantage at birth. One in two (49.3%) frequent presenters had at least one injury presentation and one (21.3%) in five had at least one presentation related to a chronic condition. CONCLUSIONS: Children with ≥4 presentations do not represent the majority of ED users. Nevertheless, they represent a disproportionate burden accounting for 15% of all paediatric ED presentations in a 12-month period. Frequent presenters were characterised by early socio-economic and health disadvantage, and childhood injury. Strategies targeting social disadvantage and childhood injury may reduce the burden of ED presentations.

Effect of maternal smoking during pregnancy on childhood type 1 diabetes: a whole-of-population study.

AIMS/HYPOTHESIS: Evidence of an association between maternal smoking during pregnancy (prenatal smoking) and childhood type 1 diabetes is mixed. Previous studies have been small and potentially biased due to unmeasured confounding. The objectives of this study were to estimate the association between prenatal smoking and childhood type 1 diabetes, assess residual confounding with a negative control design and an E-value analysis, and summarise published effect estimates from a meta-analysis. METHODS: This whole-of-population study (births from 1999 to 2013, participants aged ≤15 years) used de-identified linked administrative data from the South Australian Early Childhood Data Project. Type 1 diabetes was diagnosed in 557 children (ICD, tenth edition, Australian Modification [ICD-10-AM] codes: E10, E101-E109) during hospitalisation (2001-2014). Families not given financial assistance for school fees was a negative control outcome. Adjusted Cox proportional HRs were calculated. Analyses were conducted on complete-case (n = 264,542, type 1 diabetes = 442) and imputed (n = 286,058, type 1 diabetes = 557) data. A random-effects meta-analysis was used to summarise the effects of prenatal smoking on type 1 diabetes. RESULTS: Compared with non-smokers, children exposed to maternal smoking only in the first or second half of pregnancy had a 6% higher type 1 diabetes incidence (adjusted HR 1.06 [95% CI 0.73, 1.55]). Type 1 diabetes incidence was 24% lower (adjusted HR 0.76 [95% CI 0.58, 0.99]) among children exposed to consistent prenatal smoking, and 16% lower for exposure to any maternal smoking in pregnancy (adjusted HR 0.84 [95% CI 0.67, 1.08]), compared with the unexposed group. Meta-analytic estimates showed 28-29% lower risk of type 1 diabetes among children exposed to prenatal smoking compared with those not exposed. The negative control outcome analysis indicated residual confounding in the prenatal smoking and type 1 diabetes association. E-value analysis indicated that unmeasured confounding associated with prenatal smoking and childhood type 1 diabetes, with a HR of 1.67, could negate the observed effect. CONCLUSIONS/INTERPRETATION: Our best estimate from the study is that maternal smoking in pregnancy was associated with 16% lower childhood type 1 diabetes incidence, and some of this effect was due to residual confounding.

Associations of adverse childhood experiences with educational attainment and adolescent health and the role of family and socioeconomic factors: A prospective cohort study in the UK.

BACKGROUND: Experiencing multiple adverse childhood experiences (ACEs) is a risk factor for many adverse outcomes. We explore associations of ACEs with educational attainment and adolescent health and the role of family and socioeconomic factors in these associations. METHODS AND FINDINGS: Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective cohort of children born in southwest England in 1991-1992, we assess associations of ACEs between birth and 16 years (sexual, physical, or emotional abuse; emotional neglect; parental substance abuse; parental mental illness or suicide attempt; violence between parents; parental separation; bullying; and parental criminal conviction, with data collected on multiple occasions between birth and age 16) with educational attainment at 16 years (n = 9,959) and health at age 17 years (depression, obesity, harmful alcohol use, smoking, and illicit drug use; n = 4,917). We explore the extent to which associations are robust to adjustment for family and socioeconomic factors (home ownership, mother and partner's highest educational qualification, household social class, parity, child's ethnicity, mother's age, mother's marital status, mother's depression score at 18 and 32 weeks gestation, and mother's partner's depression score at 18 weeks gestation) and whether associations differ according to socioeconomic factors, and we estimate the proportion of adverse educational and health outcomes attributable to ACEs or family or socioeconomic measures. Among the 9,959 participants (49.5% female) included in analysis of educational outcomes, 84% reported at least one ACE, 24% reported 4 or more ACEs, and 54.5% received 5 or more General Certificates of Secondary Education (GCSEs) at grade C or above, including English and Maths. Among the 4,917 participants (50.1% female) included in analysis of health outcomes, 7.3% were obese, 8.7% had depression, 19.5% reported smoking, 16.1% reported drug use, and 10.9% reported harmful alcohol use. There were associations of ACEs with lower educational attainment and higher risk of depression, drug use, and smoking. For example, odds ratios (ORs) for 4+ ACEs compared with no ACEs after adjustment for confounders were depression, 2.4 (1.6-3.8, p < 0.001); drug use, 3.1 (2.1-4.4, p < 0.001); and smoking, 2.3 (1.7-3.1, p < 0.001). Associations with educational attainment attenuated after adjustment but remained strong; for example, the OR after adjustment for confounders for low educational attainment comparing 4+ ACEs with no ACEs was 2.0 (1.7-2.4, p < 0.001). Associations with depression, drug use, and smoking were not altered by adjustment. Associations of ACEs with harmful alcohol use and obesity were weak. For example, ORs for 4+ ACEs compared with no ACEs after adjustment for confounders were harmful alcohol use, 1.4 (0.9-2.0, p = 0.10) and obesity, 1.4 (0.9-2.2, p = 0.13) We found no evidence that socioeconomic factors modified the associations of ACEs with educational or health outcomes. Population attributable fractions (PAFs) for the adverse educational and health outcomes range from 5%-15% for 4+ ACEs and 1%-19% for low maternal education. Using data from multiple questionnaires across a long period of time enabled us to capture a detailed picture of the cohort members' experience of ACEs; however, a limitation of our study is that this resulted in a high proportion of missing data, and our analyses assume data are missing at random. CONCLUSIONS: This study demonstrates associations between ACEs and lower educational attainment and higher risks of depression, drug use, and smoking that remain after adjustment for family and socioeconomic factors. The low PAFs for both ACEs and socioeconomic factors imply that interventions that focus solely on ACEs or solely on socioeconomic deprivation, whilst beneficial, would miss most cases of adverse educational and health outcomes. This interpretation suggests that intervention strategies should target a wide range of relevant factors, including ACEs, socioeconomic deprivation, parental substance use, and mental health.

Could Greater Physical Activity Reduce Population Prevalence and Socioeconomic Inequalities in Children's Mental Health Problems? A Policy Simulation.

BACKGROUND: One in four children 5-16 years (y) of age shows signs of mental health problems in the United Kingdom; risk is higher in economically disadvantaged groups. Greater physical activity is associated with lower risk of internalizing problems such as depression and anxiety. We simulated the potential impact of population-wide physical activity interventions on overall prevalence of internalizing problems, and by family income. Interventions were based on the World Health Organization (WHO) children's target of 60 minutes (min) of moderate-to-vigorous physical activity per day and trial evidence. METHODS: Data were from the UK Millennium Cohort Study, a population-representative cohort of children born in 2000-2002. Household income (5 y) was the exposure; internalizing problems (outcome) were measured using the Strengths and Difficulties Questionnaire (11 y). Of 18,296 singletons, 6,497 had accelerometer physical activity data (mediator, manipulated to simulate interventions) at 7 y. We predicted probabilities of outcome according to exposure in marginal structural models, weighted for attrition and confounding, and adjusted for observed mediator. We then re-estimated probabilities in different physical activity intervention scenarios, assessing income inequalities in internalizing problems with risk ratios (RRs) and differences (RDs) according to income quintile. RESULTS: Simulating universal achievement of the WHO target led to little change in prevalence (10% [95% CI = 8%, 12%]) and socioeconomic inequalities in internalizing problems; RR: 2.2 (1.1, 3.4); RD: 8% [5%,13%]). More modest increases in physical activity achieved weaker results. CONCLUSIONS: Our simulations suggest that large increases in moderate-to-vigorous physical activity in the United Kingdom would have little effect on prevalence and inequalities in child mental health problems.

Educational outcomes among children with type 1 diabetes: Whole-of-population linked-data study.

BACKGROUND: Challenges with type 1 diabetes (T1D) blood glucose management and illness-related school absences potentially influence children's educational outcomes. However, evidence about the impact of T1D on children's education is mixed. The objectives were to estimate the effects of T1D on children's educational outcomes, and compare time since T1D diagnosis (recent diagnosis [≤2 years] and 3 to 10 years long exposure) on educational outcomes. METHODS: This whole-of-population study used de-identified, administrative linked-data from the South Australian Early Childhood Data Project. T1D was identified from hospital ICD-10-AM diagnosis codes (E10, ranging E101 to E109), from 2001 to 2014. Educational outcomes were measured in grade 5 by the National Assessment Program-Literacy and Numeracy (NAPLAN, 2008-2015) for children born from 1999 to 2005. Analyses were conducted using augmented inverse probability of treatment weighting. Multiple imputations was used to impute missing data. RESULTS: Among 61 445 children born in South Australia who had undertaken NAPLAN assessments, 162 had T1D. There were negligible differences in the educational outcomes of children with and without T1D, and between recently diagnosed and those with longer exposure. For example, the mean reading score was 482.8 ± 78.9 for children with T1D and 475.5 ± 74.3 for other children. The average treatment effect of 6.8 (95% CI - 6.3-19.9) reflected one-tenth of a SD difference in the mean reading score of children with and without T1D. CONCLUSION: Children with T1D performed similarly on literacy and numeracy in grade 5 (age ~ 10-years) compared to children without T1D. This could be due to effective T1D management.

Incidence of type 1 diabetes by socio-demographic characteristics among South Australian children: Whole-of-population study.

AIM: To describe and compare the incidence of type 1 diabetes (T1D) in South Australia by individual and area-level socio-economic characteristics among children aged ≤11 years. METHODS: This is a whole-of-population, data linkage study (n = 231 685) conducted in South Australia, and included children born from 2002 to 2013, hospitalisation followed from 2002 to 2014. The study used de-identified, linked administrative hospitalisation, birth and perinatal data from the South Australian Early Childhood Data Project. Incidence was calculated by identifying T1D cases from T1D-related hospitalisations using International Classification of Disease, 10th Revision, Australian Modification diagnosis codes (E10, E101-E109). RESULTS: Overall, 333 children aged ≤11 years (173 boys) were identified as having T1D. The T1D incidence rate was 23.0 per 100 000 person-years (95% confidence interval (CI): 20.7-25.7), with no sex difference. T1D incidence was higher among children whose mothers were Caucasian, private patients and whose parents were employed. For example, T1D incidence was 26.0 per 100 000 (95% CI: 22.8-29.5) among children with both parents employed, compared to 20.0 per 100 000 (95% CI: 12.3-30.6) among children with both parents unemployed. There was no clear gradient in the association between area-level socio-economic position and T1D, with highest incidence for the fourth quintile (26.5 per 100 000 (95% CI: 20.9-33.1)). The most advantaged area (19.4 per 100 000 (95% CI: 13.8-26.5)) had lower incidence than the most disadvantaged area (23.5 per 100 000 (95% CI: 18.9-28.9)). CONCLUSION: T1D incidence rates differed depending on the measures of socio-economic characteristics. Individual-level indicators showed higher incidence among more advantaged children; however, there was no clear area-level socio-economic patterning of T1D.

Temporal effects of maternal psychological distress on child mental health problems at ages 3, 5, 7 and 11: analysis from the UK Millennium Cohort Study.

BACKGROUND: Psychological distress is common among women of childbearing age, and limited longitudinal research suggests prolonged exposure to maternal distress is linked to child mental health problems. Estimating effects of maternal distress over time is difficult due to potential influences of child mental health problems on maternal distress and time-varying confounding by family circumstances. METHODS: We analysed the UK Millennium Cohort Study, a nationally representative sample with data collected throughout childhood. Adopting a marginal structural modelling framework, we investigated effects of exposure to medium/high levels of maternal psychological distress (Kessler-6 score 8+) on child mental health problems (Strengths and Difficulties Questionnaire borderline/abnormal behaviour cut-off) using maternal and child mental health data at 3, 5, 7 and 11 years, accounting for the influence of child mental health on subsequent maternal distress, and baseline and time-varying confounding. RESULTS: Prior and concurrent exposures to maternal distress were associated with higher levels of child mental health problems at ages 3, 5, 7 and 11 years. For example, elevated risks of child mental health problems at 11 years were associated with exposure to maternal distress from 3 years [risk ratio (RR) 1.27 (95% confidence interval (CI) 1.08-1.49)] to 11 years [RR 2.15 (95% CI 1.89-2.45)]. Prolonged exposure to maternal distress at ages 3, 5, 7 and 11 resulted in an almost fivefold increased risk of child mental health problems. CONCLUSIONS: Prior, concurrent and, particularly, prolonged exposure to maternal distress raises risks for child mental health problems. Greater support for mothers experiencing distress is likely to benefit the mental health of their children.

Bullying and sexual abuse and their association with harmful behaviours, antidepressant use and health-related quality of life in adulthood: a population-based study in South Australia.

BACKGROUND: Few representative sample studies have reported estimates of bullying and sexual abuse in Australia. By using face-to-face interviews and self-labelling questions, we investigated the prevalence of these forms of abuse and their relationship with current harmful behaviours (smoking dependence, excessive alcohol intake, binge eating), antidepressant use, and the physical (PCS) and mental (MCS) components of health-related quality of life. METHODS: This study was a population-based survey that investigated 2873 South Australians in 2015 (48.8 ± 18.1 years; 49.3% males). Bullying and sexual abuse (age of onset and duration) and their outcomes were investigated through household interviews. Associations were adjusted for sociodemographic variables by using regression models. RESULTS: 45.6% (95% CI 43.3-47.9) of the participants were bullied, and 10.4% (95% CI 9.1-11.9) sexually abused; 7.3% (95% CI 6.2-8.5) reported experiencing both forms of abuse. Moreover, 15.8% of those bullied and 15.0% of those sexually abused suffered from these forms of abuse for > 24 months. Smoking dependence (7.8%) was twice as frequent among those who experienced bullying for > 24 months or when sexual abuse occurred in childhood (< 10 years) or adulthood (20+ years) or lasted ≥1 month. Excessive alcohol intake (14.3%) was more frequent when bullying occurred in childhood or lasted > 24 months. Binge eating (8.1%) was more frequent among those bullied or sexually abused in adulthood, but duration did not show a clear pattern. Antidepressant use was up to four times more likely, and PCS or MCS lower among those who were bullied or sexually abused, independent of when these forms of abuse started or their duration. The cumulative adverse relationship of bullying and sexual abuse with the investigated outcomes was more evident for smoking dependence, binge eating, PCS, and MCS than for antidepressant use, but no association was observed with alcohol intake. CONCLUSIONS: The use of self-labelling questions to investigate sensitive areas such as bullying and sexual abuse in a survey is feasible. Such questions provided estimates that are consistent with findings from studies using more detailed instruments. Bullying and sexual abuse have an additive adverse association with various outcomes. Identifying survivors of both forms of abuse is important to avoid more serious consequences.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people.

BACKGROUND: Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated. OBJECTIVES: To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people. SEARCH METHODS: We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations. SELECTION CRITERIA: We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level. DATA COLLECTION AND ANALYSIS: We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies. AUTHORS' CONCLUSIONS: Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Associations of parental food-choice control and use of food to soothe with adiposity in childhood and adolescence.

BACKGROUND: Associations of parental feeding techniques with adiposity are mixed and largely rely on cross-sectional studies. We examined associations between parental food-choice control and using food to soothe at 3.5 years on adiposity at 7 and 15 years. METHODS: Participants were from the Avon Longitudinal Study of Parents and Children (n = 7312). Food-choice control was assessed using the item 'how much choice do you allow him/her in deciding what foods he eats at meals?'. Use of food to soothe was reported by mothers on the item 'how often do you use sweets or other foods to stop his/her crying or fussing?'. BMI at 7 and 15 years was converted to sex- and age-adjusted z-scores. Fat mass was assessed at 15 years using dual energy X-ray absorptiometry. RESULTS: In fully-adjusted models, children given the least choice had 0.08 lower BMI z-score at age 7 years and 0.12 lower BMI z-score,1.46 kg lower fat mass at 15 years than children with the most choices. There was no evidence of an association between using food to soothe and adiposity. CONCLUSIONS: Contrary to some studies, higher parental control over food choice was associated with lower adiposity, but use of food to soothe was not associated with adiposity at ages 7 and 15.

Bias of health estimates obtained from chronic disease and risk factor surveillance systems using telephone population surveys in Australia: results from a representative face-to-face survey in Australia from 2010 to 2013.

BACKGROUND: Emerging communication technologies have had an impact on population-based telephone surveys worldwide. Our objective was to examine the potential biases of health estimates in South Australia, a state of Australia, obtained via current landline telephone survey methodologies and to report on the impact of mobile-only household on household surveys. METHODS: Data from an annual multi-stage, systematic, clustered area, face-to-face population survey, Health Omnibus Survey (approximately 3000 interviews annually), included questions about telephone ownership to assess the population that were non-contactable by current telephone sampling methods (2006 to 2013). Univariable analyses (2010 to 2013) and trend analyses were conducted for sociodemographic and health indicator variables in relation to telephone status. Relative coverage biases (RCB) of two hypothetical telephone samples was undertaken by examining the prevalence estimates of health status and health risk behaviours (2010 to 2013): directory-listed numbers, consisting mainly of landline telephone numbers and a small proportion of mobile telephone numbers; and a random digit dialling (RDD) sample of landline telephone numbers which excludes mobile-only households. RESULTS: Telephone (landline and mobile) coverage in South Australia is very high (97%). Mobile telephone ownership increased slightly (7.4%), rising from 89.7% in 2006 to 96.3% in 2013; mobile-only households increased by 431% over the eight year period from 5.2% in 2006 to 27.6% in 2013. Only half of the households have either a mobile or landline number listed in the telephone directory. There were small differences in the prevalence estimates for current asthma, arthritis, diabetes and obesity between the hypothetical telephone samples and the overall sample. However, prevalence estimate for diabetes was slightly underestimated (RCB value of -0.077) in 2013. Mixed RCB results were found for having a mental health condition for both telephone samples. Current smoking prevalence was lower for both hypothetical telephone samples in absolute differences and RCB values: -0.136 to -0.191 for RDD landline samples and -0.129 to -0.313 for directory-listed samples. CONCLUSION: These findings suggest landline-based sampling frames used in Australia, when appropriately weighted, produce reliable representative estimates for some health indicators but not for all. Researchers need to be aware of their limitations and potential biased estimates.

The Active for Life Year 5 (AFLY5) school-based cluster randomised controlled trial: effect on potential mediators.

BACKGROUND: Active for life year 5 (AFLY5) is a school-based intervention, based on social cognitive theory, which aims to promote healthy levels of physical activity and healthy eating by improving a child's self-efficacy to make healthy choices, their knowledge of how to make such choices and prompting parents to support their children to make healthy choices. Previously published results showed no effect on the three primary outcomes and beneficial effects on three of nine secondary outcomes (time spent screen-viewing at weekends, consumption of snacks and of high energy drinks). This paper aims to determine the effect of the intervention on potential mediators. METHODS: We conducted a cluster RCT of a school-based intervention, with allocation concealed by use of a remote system. The study was undertaken in the South West of England between 2011 and 2013. Participants were school children who were age 8-9 years at baseline assessment and 9-10 years during the intervention. Potential mediators were assessed at the end of the intervention. The intervention consisted of teacher training, provision of all materials required for lessons and homeworks and written materials for school newsletters and parents. The ten potential mediators were child-reported self-efficacy for physical activity and fruit and vegetable consumption, perceived parental logistic support and modelling for their child's physical activity, parental efforts to limit their child's sedentary behaviour and modelling of healthy fruit and vegetable consumption, together with a knowledge assessment. RESULTS: We successfully recruited 60 schools with over 2,221 children; valid data for the 10 mediators were available for 87 % to 96 % of participants. Three of the ten potential mediators were greater in the intervention, compared with the control group: fruit and vegetable self-efficacy 2.2 units (95 % CI: 0.7 to 3.8), assessed on a scale 26 to 130; child-reported maternal limitation of sedentary behaviour 0.5 (0.1 to 0.8), scale 4 to 16; and knowledge 0.5 (0.2, 0.7) scale 0 to 9. Reported maternal limitation of sedentary behaviour and the child's knowledge explained 23 % of the effect of the intervention on reducing time spent on sedentary behaviour at the weekend. There was no effect on other mediators. CONCLUSIONS: Our findings suggest that the effect of the AFLY5 intervention on reducing screen-viewing at weekends was partially mediated by an effect on mothers limiting their child's time spent sedentary and on increasing the child's knowledge about healthy behaviour. However, overall our findings suggest that theory driven interventions, like AFLY5, can fail to influence most potential mediators and this may explain the failure of the intervention to improve most primary and secondary outcomes. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50133740. Registered 17/03/2011.

Health Estimates Using Survey Raked-Weighting Techniques in an Australian Population Health Surveillance System.

A challenge for population health surveillance systems using telephone methodologies is to maintain representative estimates as response rates decrease. Raked weighting, rather than conventional poststratification methodologies, has been developed to improve representativeness of estimates produced from telephone-based surveillance systems by incorporating a wider range of sociodemographic variables using an iterative proportional fitting process. This study examines this alternative weighting methodology with the monthly South Australian population health surveillance system report of randomly selected people of all ages in 2013 (n = 7,193) using computer-assisted telephone interviewing. Poststratification weighting used age groups, sex, and area of residence. Raked weights included an additional 6 variables: dwelling status, number of people in household, country of birth, marital status, educational level, and highest employment status. Most prevalence estimates (e.g., diabetes and asthma) did not change when raked weights were applied. Estimates that changed by at least 2 percentage points (e.g., tobacco smoking and mental health conditions) were associated with socioeconomic circumstances, such as dwelling status, which were included in the raked-weighting methodology. Raking methodology has overcome, to some extent, nonresponse bias associated with the sampling methodology by incorporating lower socioeconomic groups and those who are routinely not participating in population surveys into the weighting formula.

Intervention fidelity in a school-based diet and physical activity intervention in the UK: Active for Life Year 5.

BACKGROUND: Active for Life Year 5 (AFLY5) is an educational programme for Year 5 children (aged 9-10) designed to increase children's physical activity, decrease sedentary behaviour and increase fruit and vegetable intake. This paper reports findings from a process evaluation embedded within a randomised controlled trial evaluating the programme's effectiveness. It considers the fidelity of implementation of AFLY5 with a focus on three research questions: 1. To what extent was the intervention delivered as planned? 2. In what ways, if any, did the teachers amend the programme? and 3. What were the reasons for any amendments? METHODS: Mixed methods were used including data collection via observation of the intervention delivery, questionnaire, teacher's intervention delivery log and semi-structured interviews with teachers and parents. Qualitative data were analysed thematically and quantitative data were summarised using descriptive statistics. RESULTS: Following training, 42 of the 43 intervention school teachers/teaching staff (98%) were confident they could deliver the nutrition and physical activity lessons according to plan. The mean number of lessons taught was 12.3 (s.d. 3.7), equating to 77% of the intervention. Reach was high with 95% of children in intervention schools receiving lessons. A mean of 6.2 (s.d. 2.6) out of 10 homeworks were delivered. Median lesson preparation time was 10 min (IQR 10-20) and 28% of lessons were reported as having been amended. Qualitative findings revealed that those who amended the lessons did so to differentiate for student ability, update them for use with new technologies and to enhance teacher and student engagement. Teachers endorsed the aims of the intervention, but some were frustrated with having to adapt the lesson materials. Teachers also a reported tendency to delegate the physical activity lessons to other staff not trained in the intervention. CONCLUSIONS: Fidelity of intervention implementation was good but teachers' enthusiasm for the AFLY5 programme was mixed despite them believing that the messages behind the lessons were important. This may have meant that the intervention messages were not delivered as anticipated and explain why the intervention was found not to be effective. TRIAL REGISTRATION: ISRCTN50133740.

Effect of social mobility in family financial situation and housing tenure on mental health conditions among South Australian adults: results from a population health surveillance system, 2009 to 2011.

BACKGROUND: To assess the association of socioeconomic position (SEP), measured by family financial situation and housing tenure in childhood and adulthood, with mental health conditions in adulthood. METHODS: Representative cross-sectional population data were collected using a risk factor surveillance system in South Australia, Australia. Each month, a random sample were selected from the Electronic White Pages. Participants aged 25 years and above (n = 10429) were asked about doctor diagnosed anxiety, stress or depression, suicidal ideation, psychological distress, demographic and socioeconomic factors using Computer Assisted Telephone Interviewing (CATI). Social mobility measures were derived from housing status and perceived financial situation during adulthood and at 10 years of age. RESULTS: The prevalence of psychological distress was 8.1 %, current diagnosed mental health condition was 14.8 % and suicidal ideation was 4.3 %. Upward mobility in family financial situation and housing tenure was experienced by 28.6 % and 19.3 %, of respondents respectively. Downward mobility was experienced by 9.4 % for housing tenure and 11.3 % for family financial situation. In the multivariable analysis, after adjusting for age, sex, childhood family structure and adult education, downward social mobility and stable low SEP (both childhood and adulthood), in terms of both housing tenure and financial situation, were positively associated with all three mental health conditions. CONCLUSION: People with low SEP in adulthood had poor mental health outcomes regardless of their socioeconomic circumstances in childhood. Policies to improve SEP have the potential to reduce mental health conditions in the population.

Effects of simulated interventions to improve school entry academic skills on socioeconomic inequalities in educational achievement.

Randomized controlled trial evidence shows that interventions before age 5 can improve skills necessary for educational success; the effect of these interventions on socioeconomic inequalities is unknown. Using trial effect estimates, and marginal structural models with data from the Avon Longitudinal Study of Parents and Children (n = 11,764, imputed), simulated effects of plausible interventions to improve school entry academic skills on socioeconomic inequality in educational achievement at age 16 were examined. Progressive universal interventions (i.e., more intense intervention for those with greater need) to improve school entry academic skills could raise population levels of educational achievement by 5% and reduce absolute socioeconomic inequality in poor educational achievement by 15%.

Can screening 4-5 year olds accurately identify children who will have teacher-reported mental health problems when children are aged 6-7 years?

OBJECTIVE: To assess the screening accuracy of information obtained from parents of 4-5-year-old children for the purpose of identifying the children who have teacher-reported mental health problems when they are aged 6-7 years. METHOD: The study used data from the Longitudinal Study of Australian Children (LSAC) obtained when children were aged 4-5 years and 6-7 years. The level of children's mental health problems was assessed using the Strengths and Difficulties Questionnaire (SDQ) completed by parents when children were aged 4-5 years and by teachers when children were aged 6-7 years (n=2163). When children were aged 4-5 years, parenting skills were assessed using three questionnaires developed for the parent-completed LSAC questionnaire and maternal mental health was assessed using the Kessler Psychological Distress Scale (K6). RESULTS: When the level of parent-reported childhood mental health problems at 4-5 years old was used to identify children with teacher-reported mental health problems (i.e. a score in the "abnormal" range of the teacher-reported SDQ Total Difficulties Scale) when the children were aged 6-7 years, sensitivity was 26.8%, positive predictive value was 22.8%, and specificity was 92.9%. The addition of further information about the characteristics of children and their parents made only a small improvement to screening accuracy. CONCLUSIONS: Targeted interventions for preschool children may have the potential to play an important role in reducing the prevalence of mental health problems during the early school years. However, current capacity to accurately identify preschoolers who will experience teacher-reported mental health problems during the early school years is limited.

Parental socio-economic position during childhood as a determinant of self-harm in adolescence.

PURPOSE: Socio-economic position (SEP) during childhood and parental social mobility have been associated with subsequent health outcomes in adolescence and adulthood. This study investigates whether parental SEP during childhood is associated with subsequent self-harm in adolescence. METHODS: This study uses data from a prospective birth-cohort study (the Avon Longitudinal Study of Parents and Children) which followed 14,610 births in 1991-1992 to age 16-18 years (n = 4,810). The association of parental SEP recorded pre-birth and throughout childhood with self-harm was investigated using logistic regression models, with analyses conducted separately for those reporting self-harm (a) with and (b) without suicidal intent. The impact of missing data was investigated using multiple imputation methods. RESULTS: Lower parental SEP was associated with increased risk of offspring self-harm with suicidal intent, with less consistent associations evident for self-harm without suicidal intent. Associations were somewhat stronger in relation to measures of SEP in later childhood. Depressive symptoms appeared to partially mediate the associations. Adolescents of parents reporting consistently low income levels during childhood were approximately 1.5 times more likely to engage in SH than those never to report low income. CONCLUSIONS: Lower SEP during childhood is associated with the subsequent risk of self-harm with suicidal intent in adolescence. This association is stronger in those experiencing consistently lower SEP.

Can items used in 4-year-old well-child visits predict children's health and school outcomes?

To examine whether items comprising a preschool well-child check for use by family doctors in Australia with 4-5-year old children predicts health and academic outcomes at 6-7 years. The well-child check includes mandatory (anthropometry, eye/vision, ear/hearing, dental, toileting, allergy problems) and non-mandatory (processed food consumption, low physical activity, motor, behaviour/mood problems) items. The predictive validity of mandatory and non-mandatory items measured at 4-5 years was examined using data from the Longitudinal Study of Australian Children. Outcomes at 6-7 years included overweight/obesity, asthma, health care/medication needs, general health, mental health problems, quality of life, teacher-reported mathematics and literacy ability (n = 2,280-2,787). Weight or height >90th centile at 4-5 years predicted overweight/obesity at 6-7 years with 60% sensitivity, 79% specificity and 40% positive predictive value (PPV). Mood/behaviour problems at 4-5 predicted mental health problems at 6-7 years with 86% sensitivity, 40% specificity and 8% PPV. Non-mandatory items improved the discrimination between children with and without mental health problems at 6-7 years (area under the receiver operating characteristic curve 0.75 compared with 0.69 for mandatory items only), but was weak for most outcomes. Items used in a well-child health check were moderate predictors of overweight/obesity and mental health problems at 6-7 years, but poor predictors of other health and academic outcomes.

Implementation of an educational intervention to improve hand washing in primary schools: process evaluation within a randomised controlled trial.

BACKGROUND: Process evaluations are useful for understanding how interventions are implemented in trial settings. This is important for interpreting main trial results and indicating how the intervention might function beyond the trial. The purpose of this study was to examine the reach, dose, fidelity, acceptability, and sustainability of the implementation of an educational hand washing intervention in primary schools, and to explore views regarding acceptability and sustainability of the intervention. METHODS: Process evaluation within a cluster randomised controlled trial, including focus groups with pupils aged 6 to 11, semi-structured interviews with teachers and external staff who coordinated the intervention delivery, and school reports and direct observations of the intervention delivery. RESULTS: The educational package was delivered in 61.4% of schools (85.2% of intervention schools, 37.8% of control schools following completion of the trial). Teachers and pupils reacted positively to the intervention, although concerns were raised about the age-appropriateness of the resources. Teachers adapted the resources to suit their school setting and pupils. Staff coordinating the intervention delivery had limited capacity to follow up and respond to schools. CONCLUSIONS: The hand washing intervention was acceptable to schools, but its reach outside of a randomised trial, evidenced in the low proportion of schools in the control arm who received it after the trial had ended, suggests that the model of delivery may not be sustainable. TRIAL REGISTRATION: ISRCTN: ISRCTN93576146.