Adolescent inpatient activity 1999–2010: analysis of English Hospital Episode Statistics data

Objective: To investigate patterns and trends of adolescent (10–19 years) inpatient activity in England by sex, disease category, and admitting speciality. Data 9 632 844 Finished Consultant Episodes (FCEs) from English patients aged 1–19 between 1999/2000 and 2010/2011 (Hospital Episode Statistics data). Analyses Age trends by sex and major International Classification of Disease 10 (ICD10) chapter; differences in activity rates by age and sex; inpatient activity trends over the past decade, disaggregated by sex, admitting speciality and ICD10 chapter. Results: Adolescent female patients account for more activity than girls aged 1–9 (139.4 vs 107.2 FCEs/1000). Female inpatient activity increases significantly between age 10 (70.9 FCEs/1000) and 19 (281.7 FCES/1000, of which non-obstetric care accounts for 155.9 FCEs/1000). Male activity increases much less during adolescence, with lower overall rates among adolescents than younger children (93.7 vs 142.9 FCEs/1000). Between 1999 and 2010, total adolescent inpatient activity increased faster among adolescents (10–19 years) (+14.2%) than younger children (1–9 years) (+11.0%). Adolescent FCEs/1000 increased by 12.8%, including higher rates admitted under Paediatrics (+47.5%) and Paediatric Surgery (+23.2%). Adolescents were admitted across a range of specialities. Conclusions: These data challenge the belief that adolescents are a healthy group who rarely use inpatient services. In England, use of inpatient services is higher among female patients aged 10–19 years than those aged 1–9 years, while adolescent activity has increased faster than for younger children over the past 11 years. Improving service quality for adolescents will require engagement of the many different teams that care for them

Estimating the effects of preventive and weight-management interventions on the prevalence of childhood obesity in England: a modelling study

BACKGROUND: The effects of the systematic delivery of treatments for obesity are unknown. We aimed to estimate the potential effects on the prevalence of childhood obesity of systematically offering preventive and treatment interventions to eligible children in England, based on weight or health status. METHODS: For this modelling study, we developed a cross-sectional simulation model of the child and young adult population in England using data from multiple years of the Health Survey of England conducted between Jan 1, 2010, and Dec 31, 2019. Individuals were assessed for eligibility via age, BMI, and medical complications. Weight status was defined based on clinical criteria used by the UK National Institute of Health and Care Excellence. Published systematic reviews were used to estimate effect sizes for treatments, uptake, and completion for each weight-management tier. We used all available evidence, including evidence from studies that showed an unfavourable effect. We estimated the effects of two systematic approaches: a staged approach, in which children and young people were simultaneously given the most intensive treatment for which they were eligible, and a stepped approach, in which each management tier was applied sequentially, with additive effects. The primary outcomes were estimated prevalence of clinical obesity, defined as a BMI ≥98th centile on the UK90 growth chart, and difference in comparison with the estimated baseline prevalence. FINDINGS: 18 080 children and young people were included in the analytical sample. Baseline prevalence of clinical obesity was estimated to be 11·2% (95% CI 10·5 to 11·8) for children and young people aged 2-18 years. In modelling, we estimated absolute decreases in the prevalence of obesity of 0·9% (95% CI 0·1 to 1·8) for universal, preventive interventions; 0·2% (0·1 to 0·4) for interventions within a primary-care setting; 1·0% (0·1 to 2·1) for community and lifestyle interventions; 0·2% (0·0 to 0·4) for pharmaceutical interventions; and 0·4% (0·1 to 0·7) for surgical interventions. Staged care was estimated to result in an absolute decrease in the prevalence of obesity of 1·3% (-0·3 to 2·4) and stepped care was estimated to lead to an absolute decrease of 2·4% (0·1 to 4·8). INTERPRETATION: Although individual effect sizes for prevention and treatment interventions were small, when delivered at scale across England, these interventions have the potential to meaningfully contribute to reducing the prevalence of childhood obesity. FUNDING: UK National Institute for Health and Care Research

Realist trials and the testing of context-mechanism-outcome configurations: a response to Van Belle et al.

BACKGROUND: Van Belle et al. argue that our attempt to pursue realist evaluation via a randomised trial will be fruitless because we misunderstand realist ontology (confusing intervention mechanisms with intervention activities and with statistical mediation analyses) and because RCTs cannot comprehensively examine how and why outcome patterns are caused by mechanisms triggered in specific contexts. METHODS: Through further consideration of our trial methods, we explain more fully how we believe complex social interventions work and what realist evaluation should aim to do within a trial. RESULTS: Like other realists, those undertaking realist trials assume that: social interventions provide resources which local actors may draw on in actions that can trigger mechanisms; these mechanisms may interact with contextual factors to generate outcomes; and data in the 'empirical' realm can be used to test hypotheses about mechanisms in the 'real' realm. Whether or not there is sufficient contextual diversity to test such hypotheses is a contingent not a necessary feature of trials. Previous exemplars of realist evaluation have compared empirical data from intervention and control groups to test hypotheses about real mechanisms. There is no inevitable reason why randomised trials should not also be able to do so. Random allocation merely ensures the comparability of such groups without necessarily causing evaluation to lapse from a realist into a 'positivist' or 'post-positivist' paradigm. CONCLUSIONS: Realist trials are ontologically and epistemologically plausible. Further work is required to assess whether they are feasible and useful but such work should not be halted on spurious philosophical grounds

Is it possible to model the impact of calorie-reduction interventions on childhood obesity at a population level and across the range of deprivation: Evidence from the Avon Longitudinal Study of Parents and Children (ALSPAC)

BACKGROUND: Simulated interventions using observational data have the potential to inform policy and public health interventions where randomised controlled trials are not feasible. National childhood obesity policy is one such area. Overweight and obesity are primarily caused by energy-rich and low-nutrient diets that contribute to a positive net energy imbalance. Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), we investigated whether causal modelling techniques could be applied to simulate the potential impact of policy-relevant calorie-reduction interventions on population prevalence and inequalities in obesity in childhood. METHODS: Predicted probabilities of obesity at age 11 (UK90 cut offs) were estimated from logistic marginal structural models (MSM) accounting for observed calorie consumption at age 7 and confounding, overall and by maternal occupational social class. A series of population intervention scenarios were modelled to simulate daily calorie-reduction interventions that differed in effectiveness, targeting mechanism and programme uptake level. RESULTS: The estimated effect of maternal social class on obesity after accounting for confounding and observed calorie intake was provided by the controlled direct effect (CDE), in which, 18.3% of children were living with obesity at age 11 years,. A universal simulation to lower median intake to the estimated average requirement (EAR) (a 6.1% reduction in daily calories) with 75% uptake reduced overall obesity prevalence by 0.6%; there was little impact on inequalities. A targeted intervention to limit consumption to the EAR for children with above average intake reduced population obesity prevalence at 11 years by 1.5% but inequalities remained broadly unchanged. A targeted intervention for children of low-income families reduced prevalence by 0.7% and was found to slightly reduce inequalities. CONCLUSIONS: MSMs allow estimation of effects of simulated calorie-reduction interventions on childhood obesity prevalence and inequalities, although estimates are limited by the accuracy of reported calorie intake. Further work is needed to understand causal pathways and opportunities for intervention. Nevertheless, simulated intervention techniques have promise for informing national policy where experimental data are not available

Using qualitative research to explore intervention mechanisms: findings from the trial of the Learning Together whole-school health intervention.

BACKGROUND: This study reports on qualitative research conducted within a randomised controlled trial to explore possible intervention mechanisms. It focuses on the 'Learning Together' whole-school intervention delivered in secondary schools in England from 2014 to 2017 aiming to prevent bullying and aggression and improve student health. Intervention schools received staff training in restorative practice, a social and emotional learning curriculum, and an external facilitator and manual to convene and run a student/staff action group tasked with coordinating the intervention, focusing this on local needs. METHODS: Informed by realist approaches to evaluation, we analysed qualitative data to explore intervention mechanisms and how these might interact with school contexts to generate outcomes. Qualitative analysis drew on 45 interviews and 21 focus groups across three case-study schools and employed thematic content analysis to explore how intervention resources were taken up and used by local actors, how participants described the intervention mechanisms that then ensued, and how these might have generated beneficial outcomes. RESULTS: The thematic content analysis identified three social mechanisms that recurred in participant accounts: (1) building student commitment to the school community, (2) building healthy relationships by modelling and teaching pro-social skills, and (3) de-escalating bullying and aggression and enabling re-integration within the school community. CONCLUSIONS: Our analysis provides in-depth exploration of possible mechanisms and the contextual contingencies associated with these, allowing refinement of the initial intervention theory of change. TRIAL REGISTRATION: ISRCTN registry 10751359 . Registered on 11 March 2014

Correction to: Using qualitative research to explore intervention mechanisms: findings from the trial of the learning together whole-school health intervention.

An amendment to this paper has been published and can be accessed via the original article

Childhood obesity and device-measured sedentary behavior : an instrumental variable analysis of 3,864 mother-offspring pairs

Objective Intergenerational data on mother-offspring pairs were utilized in an instrumental variable analysis to examine the longitudinal association between BMI and sedentary behavior. Methods The sample included 3,864 mother-offspring pairs from the 1970 British Cohort Study. Height and weight were recorded in mothers (age 31 [5.4] years) and offspring (age 10 years) and repeated in offspring during adulthood. Offspring provided objective data on sedentary behavior (7-day thigh-worn activPAL) in adulthood at age 46 to 47 years. Results Maternal BMI, the instrumental variable, was associated with offspring BMI at age 10 (change per kg/m(2), beta = 0.11; 95% CI: 0.09 to 0.12), satisfying a key assumption of instrumental variable analyses. Offspring (change per kg/m(2), beta = 0.010; 95% CI: -0.02 to 0.03 h/d) and maternal BMI (beta = 0.017; 95% CI: 0.001 to 0.03 h/d) was related to offspring sedentary time, suggestive of a causal impact of BMI on sedentary behavior (two-stage least squares analysis, beta = 0.18 [SE 0.08], P = 0.015). For moderate-vigorous physical activity, there were associations with offspring BMI (beta = -0.010; 95% CI: -0.017 to -0.004) and maternal BMI (beta = -0.007; 95% CI: -0.010 to -0.003), with evidence for causality (two-stage least squares analysis, beta = -0.060 [SE 0.02], P = 0.001). Conclusions There is strong evidence for a causal pathway linking childhood obesity to greater sedentary behavior

Associations between socio-economic status (including school- and pupil-level interactions) and student perceptions of school environment and health in English secondary schools

This article examines interactions between school-level and pupil-level measures of socio-economic status for pupil reports of the school environment and a range of risk behaviours and health outcomes. The baseline survey for the INCLUSIVE trial provided data on pupil affluence and pupil reports of the school environment, smoking, drinking, anti-social behaviour at school, quality of life and psychological wellbeing for over 6,000 pupils (aged 11–12 years) in 40 schools within a 1-hour train journey from central London. The level of socio-economic disadvantage of the school was measured using the percentage of pupils eligible for free school meals. Multilevel regression models examined the association between pupil affluence, the socio-economic composition of the school and the interaction between these with the school environment, risk behaviours and health outcomes. Our findings provide some evidence for interactions, suggesting that less affluent pupils reported lower psychological wellbeing and quality of life in schools with more socio-economically advantaged intakes. There appears to be a complex relationship for anti-social behaviour. Where pupil affluence and school socio-economic composition were discordant, pupils reported a higher number of anti-social behaviours. This article provides further evidence that less affluent pupils are more likely to engage in a variety of risk behaviours and experience worse health outcomes when they attend schools with more socio-economically advantaged intakes, supporting some of the mechanisms described in the theory of human functioning and school organisation