Healthy Cities Phase V evaluation: further synthesizing realism

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phase

Troubled childhoods cast long shadows : Studies of childhood adversity and premature mortality in a Swedish post-war birth cohort

Taking a life course approach can help us to understand health inequalities. This thesis illustrates that socially-patterned childhood experiences might play a critical role for inequalities in mortality. The association between childhood adversity and premature mortality is investigated in the context of a 1953 Stockholm birth cohort. Over a series of four empirical studies, it is shown that childhood adversity is a major risk factor for premature mortality, and is a significant contributor to socioeconomic inequalities in mortality. More specifically, Study I found that indicators of early life socioeconomic disadvantage and childhood adversity were individually associated with adult mortality. When all of these co-occurring indicators were studied simultaneously, involvement with child welfare services – specifically involvement resulting in placement in out-of-home care – was the indicator most robustly associated with premature mortality in adulthood. Based on the results Study I, involvement with child welfare services was used as a proxy for childhood adversity the following three studies. Study II showed that involvement with child welfare services could explain almost half of the education and income gradients in life-expectancy between ages 29–67. Study III demonstrated that the increased mortality risk among adults who were placed in out-of-home care as children persisted to midlife. Moreover, increased mortality risks after out-of-home care were not unique to the Swedish welfare context but could be verified in a cohort from Great Britain. Finally, Study IV found that adults who experienced involvement with child welfare services not only had increased risks of major diseases in adulthood, but also had worse survival prospects after a first hospitalisation. Involvement with child welfare services, specifically placement in out-of-home care, can have consequences for socioeconomic attainment, and physical and mental health. Even in this cohort that entered adulthood during some of the most generous years of the Swedish welfare state, the unequal distribution of life chances following experiences of childhood adversity was not eliminated. These empirical studies extend our understanding of how childhood adversity contributes to the complex processes that generate inequalities in mortality. The results further indicate that it is never too early nor too late to prevent inequalities in health

Troubled childhoods cast long shadows : Studies of childhood adversity and premature mortality in a Swedish post-war birth cohort

Taking a life course approach can help us to understand health inequalities. This thesis illustrates that socially-patterned childhood experiences might play a critical role for inequalities in mortality. The association between childhood adversity and premature mortality is investigated in the context of a 1953 Stockholm birth cohort. Over a series of four empirical studies, it is shown that childhood adversity is a major risk factor for premature mortality, and is a significant contributor to socioeconomic inequalities in mortality. More specifically, Study I found that indicators of early life socioeconomic disadvantage and childhood adversity were individually associated with adult mortality. When all of these co-occurring indicators were studied simultaneously, involvement with child welfare services – specifically involvement resulting in placement in out-of-home care – was the indicator most robustly associated with premature mortality in adulthood. Based on the results Study I, involvement with child welfare services was used as a proxy for childhood adversity the following three studies. Study II showed that involvement with child welfare services could explain almost half of the education and income gradients in life-expectancy between ages 29–67. Study III demonstrated that the increased mortality risk among adults who were placed in out-of-home care as children persisted to midlife. Moreover, increased mortality risks after out-of-home care were not unique to the Swedish welfare context but could be verified in a cohort from Great Britain. Finally, Study IV found that adults who experienced involvement with child welfare services not only had increased risks of major diseases in adulthood, but also had worse survival prospects after a first hospitalisation. Involvement with child welfare services, specifically placement in out-of-home care, can have consequences for socioeconomic attainment, and physical and mental health. Even in this cohort that entered adulthood during some of the most generous years of the Swedish welfare state, the unequal distribution of life chances following experiences of childhood adversity was not eliminated. These empirical studies extend our understanding of how childhood adversity contributes to the complex processes that generate inequalities in mortality. The results further indicate that it is never too early nor too late to prevent inequalities in health

Cultivating Well-Being : A study on Community Gardening and Health in Berlin and Paris

This paper reports experiences of health and well-being common to actors in community gardens in Berlin and Paris. Community gardening has become an ever growing phenomenon since the 1990s, and to a larger extend since 2000 in western European cities. Despite the promising research from the US that has shown that community gardens have a potential for health promotion, there is a dearth of evidence from Europe. This study tries to fill this gap and maps the potential of community gardens for health and well-being as explained and experienced by the gardeners. The effect of community garden projects on human health and well-being cannot be reduced to the effect of nature on health alone. This study shows that there are at least two other major mechanisms at play, if we want to understand the phenomenon or evaluate its effects, namely the effects of community and 'free and open spaces'. Gardeners report health-related experiences with green space, such as stress relief and feeling of calm and vitality and increased well-being through sensual experiences and observing nature. Furthermore the garden projects open up a social space, which for many gardeners creates experiences of health through regular social contact, experiences of joy of sharing and having activities together. Furthermore, the community garden project was proposed to create a context and opportunities for flow, creativity and self-efficacy if it is a free and open space. However, not all experiences on well-being in CGPs are postive, and to all these spaces and their effects there are also certain limitations and conditions. Moreover, this study makes a theoretical contribution to the concept of health and well-being on the basis of the fuzziness around the concept of health encountered in the field. I propose that a holistic concept of health might be most suitable to describe health related to bottom-up community action like community gardens. To assess the effects of such projects in terms of well-being, this concepts should be dissentagled into the concept of health and happiness, whereas happiness in turn relates not only to life satisfaction but also to eudaimonian happiness related to meaning and doing good. Although this research project could not be comprehensive enough to provide all necessary evidence to evaluate health effects of community gardens, we believe that it provides viable paths for investigations into community driven health promotion and emerging healthy settings

Cumulative Childhood Adversity and Long-Term Educational Outcomes in Individuals with Out-of-Home Care Experience : Do Multiples Matter for a Population Defined by Adversity?

Previous research has demonstrated a graded relationship between cumulative childhood adversity and adverse later outcomes. Individuals with out-of-home care (OHC) experience constitute a population characterised by both childhood and educational disadvantages. Based on a fifty-year follow-up of a Stockholm cohort born in 1953, the purpose of this study was to examine the associations between cumulative childhood adversity and long-term educational outcomes in this group. The cumulative disadvantage perspective suggests that there would be a negative association, while the disadvantage saturation perspective implies that cumulative adversity would be less consequential for disadvantaged individuals. By means of multigroup path analysis, we furthermore asked whether this association may differ in relation to individuals with child welfare contact (CWC) and to the general population (GP). Adjusting for socioeconomic conditions and cognitive ability, cumulative childhood adversity had a negative influence on midlife educational attainment in the GP. However, it did not seem to influence the educational outcomes of neither OHC experienced individuals nor individuals with other types of CWC. The results of this study thus lend support to the disadvantage saturation perspective. Further studies are needed to explore this relationship.

Rocks, Dandelions or Steel Springs: Understanding Resilience from a Public Health Perspective

The multifaceted concept of resilience is widely used to describe individual or societal abilities to withstand and adjust to external pressures. In relation to health, resilience can help us to understand a positive health development despite adverse circumstances. The authors of this article aimed to disentangle this complex concept by elaborating on three metaphors commonly used to describe resilience. Similarities and differences between resilience as a rock, a dandelion, and a steel spring are discussed. The metaphors partly overlap but still provide slightly different perspectives on the development and manifestation of resilience. With reference to longitudinal studies of long-term health development, the article also elaborates on how resilience relates to temporal dimensions commonly used in epidemiological studies: age, cohort, and period. Moreover, the interaction between resilience at individual, organizational, and societal levels is discussed. In conclusion, it is argued that public health sciences have great potential to further a theoretical discussion that improves our understanding of resilience and promotes the integration of individual- and community-level perspectives on resilience

Troubled childhoods cast long shadows : Childhood adversity and premature all-cause mortality in a Swedish cohort

Experiences of childhood adversity are common and have profound health impacts over the life course. Yet, studying health outcomes associated with childhood adversity is challenging due to a lack of conceptual clarity of childhood adversity, scarce prospective data, and selection bias. Using a 65-year follow-up of a Swedish cohort born in 1953 (n = 14,004), this study examined the relationship between childhood adversity (ages 0-18) and premature all-cause mortality (ages 19-65). Childhood adversity was operationalized as involvement with child welfare services, household dysfunction, and disadvantageous family socioeconomic conditions. Survival models were used to estimate how much of the association between child welfare service involvement and mortality could be explained by household dysfunction and socioeconomic conditions. Results show that individuals who were involved with child welfare services had higher hazards of dying prematurely than their majority population peers. These risks followed a gradient, ranging from a hazard ratio of 3.08 (95% CI: 2.68-3.53) among those placed in out-of-home care, followed by individuals subjected to in-home services who demonstrated a hazard ratio of 2.53 (95% CI: 1.93-3.32), to a hazard ratio of 1.81 among those investigated and not substantiated (95% CI: 1.55-2.12). Associations between involvement with child welfare services and premature all-cause mortality were robust to adjustment for household dysfunction and disadvantageous family socioeconomic conditions. Neither household dysfunction nor socioeconomic conditions were related with mortality independent of child welfare services involvement. This study suggests that involvement with child welfare services is a viable proxy for exposure to childhood adversity and avoids pitfalls of self-reported or retrospective measures

Does time heal all wounds? Life course associations between child welfare involvement and mortality in prospective cohorts from Sweden and Britain

Child welfare involvement reflects childhood adversity and is associated with increased adult mortality, but it remains unclear how this association changes over the life course. Drawing on the Stockholm Birth Cohort Multigenerational Study (Sweden) and the National Childhood Development Study (Great Britain) this study examines whether inequalities within these cohorts diverge or converge. Involvement with child welfare services (ICWS) is divided into two levels (‘child welfare contact’ and ‘out-of-home care’). For each cohort, we quantify absolute health inequalities as differences in cumulative probabilities of death (18–58 years) and temporary life expectancy; and relative inequalities as hazard ratios in ten-year intervals and ratios of lifetime lost. Persistently, ICWS was associated with premature mortality. The strength of the association varied by age, sex and level of ICWS. Consistently across both countries, the most robust relationship was between out-of-home care and mortality, with statistically significant age-specific hazard ratios ranging between 1.8 and 3.4 for males and 1.8–2.1 for females. Child welfare contact that did not result in out-of-home placement showed less consistent results. Among females the mortality gap developed later compared to males. Estimates attenuate after controlling for family socioeconomic and other background variables but patterns remain intact. Our results show that absolute inequalities widen with increasing age, while relative inequalities might peak in early adulthood and then stabilize in midlife. The relative disadvantage among looked-after children in early adulthood is heightened by overall low rates of mortality at this age. Absolute inequality increases with age, highlighting the weight of the accumulation of disadvantage in mortality over time. The bulk of excess deaths that could be attributed to ICWS occurs from midlife onwards. Mechanisms that uphold the disadvantage after childhood experiences require further exploration. This study highlights that the association between out-of-home care and premature mortality seems to transcend welfare systems