Reducing low birth weight: prioritizing action to address modifiable risk factors

Background Low birth weight (LBW) affects 6.9% of all UK births and has remained largely unchanged for many years. The United Nations and theWorld Health Assembly have set targets to substantially reduce global incidence. Understanding the contribution of modifiable risk factors to the burden of LBW is required to ensure appropriate interventions are in place to achieve this reduction. Methods Data from published studies on the risks from key modifiable factors were used alongside prevalence data from theWelsh population to calculate the population attributable risk for each factor individually and in combination. Results Fourteen risk factors accounted for nearly half of LBW births, and 60% of those to younger mothers (,25 years). Tobacco smoke exposure was the largest contributor.We estimated that smoking in pregnancy was a factor in one in eight LBW births, increasing to one in five for women aged under 25. Conclusions Risk factors are interrelated and inequitably distributed within the population. Exposure to one factor increases the likelihood of exposure to a constellation of factors further increasing risk. Action to address LBW must consider groups where the risk factors are most prevalent and address these risk factors together using multi-component interventions

Adverse childhood experiences during childhood and academic attainment at age 7 and 11 years: an electronic birth cohort study

Objectives Adverse childhood experiences (ACEs) have a negative impact on childhood health, but their impact on education outcomes is less well known. We investigated whether or not ACEs were associated with reduced educational attainment at age 7 and 11 years. Study design The study design used in the study is a population-based electronic cohort study. Methods We analysed data from a total population electronic child cohort in Wales, UK. ACEs (exposures) were living with an adult household member with any of (i) serious mental illness, (ii) common mental disorder (CMD), (iii) an alcohol problem; (iv) child victimisation, (v) death of a household member and (vi) low family income. We used multilevel logistic regression to model exposure to these ACEs and not attaining the expected level at statutory education assessments, Key Stage (KS) 1 and KS2 separately, adjusted for known confounders including perinatal, socio-economic and school factors. Results There were 107,479 and 43,648 children included in the analysis, with follow-up to 6–7 years (KS1) and 10–11 years (KS2), respectively. An increased risk of not attaining the expected level at KS1 was associated with living with adult household members with CMD (adjusted odds ratio [aOR]: 1.13 [95% confidence interval [CI]: 1.09–1.17]) or an alcohol problem (adjusted odds ratio [aOR]: 1.16 [95% confidence interval [CI]: 1.10–1.22]), childhood victimisation (adjusted odds ratio [aOR]: 1.58 [95% confidence interval [CI]: 1.37–1.82]), death of a household member (adjusted odds ratio [aOR]: 1.14 [95% confidence interval [CI]: 1.04–1.25]) and low family income (adjusted odds ratio [aOR]: 1.92 [95% confidence interval [CI]: 1.84–2.01]). Similar results were observed for KS2. Children with multiple adversities had substantially increased odds of not attaining the expected level at each educational assessment. Conclusion The educational potential of many children may not be achieved due to exposure to adversity in childhood. Affected children who come in to contact with services should have relevant information shared between health and care services, and schools to initiate and facilitate a coordinated approach towards providing additional support and help for them to fulfil their educational potential, and subsequent economic and social participation

Mental health selection: Common mental disorder and migration between multiple states of deprivation in a UK cohort

Objectives To assess whether the direction of movement along the social gradient was associated with changes in mental health status. Design Longitudinal record-linkage study using a multistate model. Setting Caerphilly, Wales, UK between 2001 and 2015. Participants The analytical sample included 10 892 (60.8% female) individuals aged 18-74 years. Primary and secondary outcome measures Deprivation change at lower super output area level using the 2008 Welsh Index of Multiple Deprivation. Mental health was assessed in 2001 and 2008 using the Mental Health Inventory subscale of the short-form 36 V.2. Results Mental health selection was shown whereby individuals with common mental health disorders were less likely to move to areas of lower deprivation but more likely to move to areas of greater deprivation. Conclusion Poor mental health seems to drive health selection in a similar way to poor physical health. Therefore, funding targeted at areas of higher deprivation should consider the demand to be potentially higher as individuals with poor mental health may migrate into that area

Long-term outcomes of urinary tract infection (UTI) in Childhood (LUCI): protocol for an electronic record-linked cohort study

Funding This project has been funded by the Welsh Government through Health and Care Research Wales (project number 1068). Acknowledgments We acknowledge the support and input from Sarah Jones, our parent representative for the study. We are also grateful to the DUTY and EURICA participants for their agreement for continued use of their data for this study. The Centre for Trials Research receives funding from Health and Care Research Wales and Cancer Research UK. Wales Centre for Primary and Emergency Care Research (PRIME Centre Wales) receives funding from Health and Care Research Wales. The authors are supported by the Farr Institute CIPHER, funded by Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute of Health Research, the National Institute for Social Care and Health Research (Welsh Assembly Government), the Chief Scientist Office (Scottish Government Health Directorates), and the Wellcome Trust (MRC grant number MR/K006525/1) and the National Centre for Population Health and Wellbeing Research (NCPHWR). Ethics approval Ethics approval of the study has been given by the Research Ethics Committee for Wales (16/WA/0166) and the transfer and use of identifiable data has been approved by the Health Research Authority’s (HRA) Confidentiality Advisory Group (CAG) (16/CAG/0114).Peer reviewedPublisher PD

Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS.

Objective: To estimate the direct healthcare cost of being overweight or obese throughout pregnancy to the National Health Service in Wales. Design: Retrospective prevalence-based study. Setting: Combined linked anonymised electronic datasets gathered on a cohort of women enrolled on the Growing Up in Wales: Environments for Healthy Living (EHL) study. Women were categorised into two groups: normal body mass index (BMI; n=260) and overweight/obese (BMI>25; n=224). Participants: 484 singleton pregnancies with available health service records and an antenatal BMI. Primary outcome measure: Total health service utilisation (comprising all general practitioner visits and prescribed medications, inpatient admissions and outpatient visits) and direct healthcare costs for providing these services in the year 2011–2012. Costs are calculated as cost of mother (no infant costs are included) and are related to health service usage throughout pregnancy and 2 months following delivery. Results: There was a strong association between healthcare usage cost and BMI ( p<0.001). Adjusting for maternal age, parity, ethnicity and comorbidity, mean total costs were 23% higher among overweight women (rate ratios (RR) 1.23, 95% CI 1.230 to 1.233) and 37% higher among obese women (RR 1.39, 95% CI 1.38 to 1.39) compared with women with normal weight. Adjusting for smoking, consumption of alcohol, or the presence of any comorbidities did not materially affect the results. The total mean cost estimates were £3546.3 for normal weight, £4244.4 for overweight and £4717.64 for obese women. Conclusions: Increased health service usage and healthcare costs during pregnancy are associated with increasing maternal BMI; this was apparent across all health services considered within this study. Interventions costing less than £1171.34 per person could be cost-effective if they reduce healthcare usage among obese pregnant women to levels equivalent to that of normal weight women

Risk of emergency hospital admission in children associated with mental disorders and alcohol misuse in the household: an electronic birth cohort study

Background: Mental disorders and alcohol misuse are common in families but their effects on the physical health of children are not known. We investigated the risk of emergency hospital admissions during childhood associated with living with an adult who has a mental health disorder, or who had an alcohol-related hospital admission. Methods: We did this cohort study in a total population electronic child cohort in Wales, UK, which includes all children who live in Wales or with a mother who is resident in Wales. We used Cox regression to model time to first emergency hospital admission during the first 14 years of life associated with living with an adult who has a mental health disorder, or who had an alcohol-related hospital admission. We adjusted our results for social deprivation and perinatal risk factors. Findings: We included data for 253 717 children with 1 015 614 child-years of follow-up. Living with an adult with a mental disorder was associated with an increased risk of emergency admission for all causes (adjusted hazard ratio [aHR] 1·17, 95% CI 1·16–1·19), for injuries and external causes (1·14, 1·11–1·18), and childhood victimisation (1·55, 1·44–1·67). Children living with a household member who had an alcohol-related hospital admission had a significantly higher risk of emergency admissions for injuries and external causes (aHR 1·13, 95% CI 1·01–1 ·26) and victimisation (1·39, 1·00–1·94), but not for all-cause emergency admissions (1·01, 0·93–1·09). Interpretation: The increased risk of emergency admissions in children associated with mental disorders and alcohol misuse in the household supports the need for policy measures to provide support to families that are affected. Funding: Economic and Social Research Council, Medical Research Council, Alcohol Research UK, Public Health Wales

Drinking beer, wine or spirits – does it matter for inequalities in alcohol-related hospital admission? A record-linked longitudinal study in Wales

Background: Alcohol-related harm has been found to be higher in disadvantaged groups, despite similar alcohol consumption to advantaged groups. This is known as the alcohol harm paradox. Beverage type is reportedly socioeconomically patterned but has not been included in longitudinal studies investigating record-linked alcohol consumption and harm. We aimed to investigate whether and to what extent consumption by beverage type, BMI, smoking and other factors explain inequalities in alcohol-related harm. Methods: 11,038 respondents to the Welsh Health Survey answered questions on their health and lifestyle. Responses were record-linked to wholly attributable alcohol-related hospital admissions (ARHA) eight years before the survey month and until the end of 2016 within the Secure Anonymised Information Linkage (SAIL) Databank. We used survival analysis, specifically multi-level and multi-failure Cox mixed effects models, to calculate the hazard ratios of ARHA. In adjusted models we included the number of units consumed by beverage type and other factors, censoring for death or moving out of Wales. Results: People living in more deprived areas had a higher risk of admission (HR 1.75; 95% CI 1.23–2.48) compared to less deprived. Adjustment for the number of units by type of alcohol consumed only reduced the risk of ARHA for more deprived areas by 4% (HR 1.72; 95% CI 1.21–2.44), whilst adding smoking and BMI reduced these inequalities by 35.7% (HR 1.48; 95% CI 1.01–2.17). These social patterns were similar for individual-level social class, employment, housing tenure and highest qualification. Inequalities were further reduced by including either health status (16.6%) or mental health condition (5%). Unit increases of spirits drunk were positively associated with increasing risk of ARHA (HR 1.06; 95% CI 1.01–1.12), higher than for other drink types. Conclusions: Although consumption by beverage type was socioeconomically patterned, it did not help explain inequalities in alcohol-related harm. Smoking and BMI explained around a third of inequalities, but lower socioeconomic groups had a persistently higher risk of (multiple) ARHA. Comorbidities also explained a further proportion of inequalities and need further investigation, including the contribution of specific conditions. The increased harms from consumption of stronger alcoholic beverages may inform public health policy

An exploration of factors affecting the long term psychological impact and deterioration of mental health in flooded households

The long term psychological effect of the distress and trauma caused by the memory of damage and losses associated with flooding of communities remains an under researched impact of flooding. This is particularly important for communities that are likely to be repeatedly flooded where levels of mental health disorder will damage long term resilience to future flooding.There are a variety of factors that affect the prevalence of mental health disorders in the aftermath of flooding including pre-existing mental health, socio-economic factors and flood severity. However previous research has tended to focus on the short term impacts immediately following the flood event and much less focus has been given to the longer terms effects of flooding. Understanding of factors affecting the longer term mental health outcomes for flooded households is critical in order to support communities in improving social resilience. Hence, the aim of this study was to explore the characteristics associated with psychological distress and mental health deterioration over the longer term.The research examined responses from a postal survey of households flooded during the 2007 flood event across England. Descriptive statistics, correlation analysis and binomial logistic regression were applied to data representing household characteristics, flood event characteristics and post-flood stressors and coping strategies. These factors were related to reported measures of stress, anxiety, depression and mental health deterioration. The results showed that household income, depth of flooding; having to move out during reinstatement and mitigating actions are related to the prevalence of psycho-social symptoms in previously flooded households. In particular relocation and household income were the most predictive factors. The practical implication of these findings for recovery after flooding are: to consider the preferences of households in terms of the need to move out during restorative building works and the financial resource constraints that may lead to severe mental hardship. In addition the findings suggest that support with installing mitigation measures may lead to improved mental health outcomes for communities at risk

Life expectancy inequalities in Wales before COVID-19: an exploration of current contributions by age and cause of death and changes between 2002 and 2018

Objectives The COVID-19 pandemic in Wales and the UK has highlighted significant and historic inequalities in health between social groups. To better understand the composition of these inequalities and inform planning after the pandemic, we undertook a decomposition of life expectancy inequalities between the most and least deprived quintiles for men and women by age and cause of death and explored trends between 2002 and 2018. Study design Statistical decomposition of life expectancy inequalities by age and cause of death using routine population mortality datasets. Methods We used routine statistics from the Office for National Statistics for the period 2002–2018 on population and deaths in Wales stratified by age, gender, Welsh Index of Multiple Deprivation (WIMD) 2019 quintile and cause of death, categorised by International Classification of Disease, version 10, code into 15 categories of public health relevance. We aggregated data to 3-year rolling figures to account for low numbers of events in some groups annually. Next, we estimated life expectancy at birth by quintile, gender and period using life table methods. Lastly, we performed a decomposition analysis using the Arriaga method to identify the specific disease categories and ages at which excess deaths occur in more disadvantaged areas to highlight potential areas for action. Results Life expectancy inequalities between the most and least WIMD quintiles rose for both genders between 2002 and 2018: from 4.69 to 6.02 years for women (an increase of 1.33 years) and from 6.34 to 7.42 years for men (an increase of 1.08 years). Exploratory analysis of these trends suggested that the following were most influential for women: respiratory disease (1.50 years), cancers (1.36 years), circulatory disease (1.35 years) and digestive disease (0.51 years). For men, the gap was driven by circulatory disease (2.01 years), cancers (1.39 years), respiratory disease (1.25 years), digestive disease (0.79 years), drug- and alcohol-related conditions (0.54 years) and external causes (0.54 years). Contributions for women from respiratory disease, cancers, dementia and drug- and alcohol-related conditions appeared to be increasing, while among men, there were rising contributions from respiratory, digestive and circulatory disease. Conclusions Life expectancy inequalities in Wales remain wide and have been increasing, particularly among women, with indications of worsening trends since 2010 following the introduction of fiscal austerity. As agencies recover from the pandemic, these findings should be considered alongside any resumption of services in Wales or future health and public policy

Interventions that enhance health services for parents and infants to improve child development and social and emotional well-being in high-income countries: A systematic review

Background: Experiences in the first 1000 days of life have a critical influence on child development and health. Health services that provide support for families need evidence about how best to improve their provision. Methods: We systematically reviewed the evidence for interventions in high-income countries to improve child development by enhancing health service contact with parents from the antenatal period to 24 months postpartum. We searched 15 databases and trial registers for studies published in any language between 01 January 1996 and 01 April 2016. We also searched 58 programme or organisation websites and the electronic table of contents of eight journals. Results: Primary outcomes were motor, cognitive and language development, and social-emotional well-being measured to 39 months of age (to allow the interventions time to produce demonstrable effects). Results: were reported using narrative synthesis due to the variation in study populations, intervention design and outcome measurement. 22 of the 12 986 studies identified met eligibility criteria. Using Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group criteria, the quality of evidence overall was moderate to low. There was limited evidence for intervention effectiveness: positive effects were seen in 1/6 studies for motor development, 4/11 for language development, 4/8 for cognitive development and 3/19 for social-emotional well-being. However, most studies showing positive effects were at high/unclear risk of bias, within-study effects were inconsistent and negative effects were also seen. Intervention content and intensity varied greatly, but this was not associated with effectiveness. Conclusions: There is insufficient evidence that interventions currently available to enhance health service contacts up to 24 months postpartum are effective for improving child development. There is an urgent need for robust evaluation of existing interventions and to develop and evaluate novel interventions to enhance the offer to all families