Health and financial burden of adverse childhood experiences in England and Wales: a combined primary data study of five surveys

OBJECTIVE

To estimate the health and financial burden of adverse childhood experiences (ACEs) in England and Wales.

DESIGN

The study combined data from five randomly stratified cross-sectional ACE studies. Population attributable fractions (PAFs) were calculated for major health risks and causes of ill health and applied to disability adjusted life years (DALYs), with financial costs estimated using a modified human capital method.

SETTING

Households in England and Wales.

PARTICIPANTS

15 285 residents aged 18-69.

OUTCOME MEASURES

The outcome measures were PAFs for single (1 ACE) and multiple (2-3 and ≥4 ACEs) ACE exposure categories for four health risks (smoking, alcohol use, drug use, high body mass index) and nine causes of ill health (cancer, type 2 diabetes, heart disease, respiratory disease, stroke, violence, anxiety, depression, other mental illness); and annual estimated DALYs and financial costs attributable to ACEs.

RESULTS

Cumulative relationships were found between ACEs and risks of all outcomes. For health risks, PAFs for ACEs were highest for drug use (Wales 58.8%, England 52.6%), although ACE-attributable smoking had the highest estimated costs (England and Wales, £7.8 billion). For causes of ill health, PAFs for ACEs were highest for violence (Wales 48.9%, England 43.4%) and mental illness (ranging from 29.1% for anxiety in England to 49.7% for other mental illness in Wales). The greatest ACE-attributable costs were for mental illness (anxiety, depression and other mental illness; England and Wales, £11.2 billion) and cancer (£7.9 billion). Across all outcomes, the total annual ACE-attributable cost was estimated at £42.8 billion. The majority of costs related to exposures to multiple rather than a single ACE (ranging from 71.9% for high body mass index to 98.3% for cancer).

CONCLUSIONS

ACEs impose a substantial societal burden in England and Wales. Policies and practices that prevent ACEs, build resilience and develop trauma-informed services are needed to reduce burden of disease and avoidable service use and financial costs across health and other sectors.

SAT0102 NONINFLAMMATORY PAIN IS A FREQUENT PHENOMENON IN RHEUMATOID ARTHRITIS AND RESPONDS WELL TO TREATMENT WITH SARILUMAB

Background:

Inflammation is clearly a key driver of pain in rheumatoid arthritis (RA). However, in some patients the level of pain exceeds what would be expected based on the amount of synovitis observed, which may indicate the presence of noninflammatory pain (NIP). Interleukin-6 (IL-6) has been shown in animal models to increase sensitization to pain and may play a role in NIP.

Objectives:

To assess the effect of sarilumab, a human IL-6 receptor inhibitor approved for the treatment of adults with moderate to severely active RA, on NIP and disease activity, stratified by baseline (BL) NIP status.

Methods:

The analysis included data from three Phase 3 studies of sarilumab: MOBILITY (NCT01061736), MONARCH (NCT02332590), and TARGET (NCT01709578). Patients received double-blind placebo or sarilumab 150 mg or 200 mg subcutaneously (SC) every 2 weeks (q2w), plus weekly csDMARD (MOBILITY and TARGET), or adalimumab 40 mg or sarilumab 200 mg SC q2w as monotherapy (MONARCH).

NIP was defined using an established formula: tender 28-joint count (TJC) – swollen 28-joint count (SJC) ≥7.1,2Patients were assessed for NIP at study BL and for change in NIP status at Weeks 12 and 24. The proportion of patients achieving ACR20/50/70, Clinical Disease Activity Index (CDAI) ≤10, and DAS28-CRP <3.2 at Week 24 was assessed in patients with and without BL NIP. No inferential statistics were performed.

Results:

Of 2112 patients in the analysis, 490 (23%) met the criteria for NIP at study BL: MOBILITY, n = 294/1197 (25%); MONARCH, n = 90/369 (24%); TARGET, n = 106/546 (19%). BL demographics were similar for patients with or without BL NIP: mean age (SD) was 52.6 (10.7) versus 51.2 (12.3) years, and 85% versus 81% were female. Patients with BL NIP had higher CDAI, DAS28-CRP, pain Visual Analog Scale (VAS), and TJC at BL versus patients without NIP (Table). Of patients with NIP at BL, those who received sarilumab were more likely to have no NIP at Weeks 12 and 24 versus patients who received placebo or adalimumab (Figure 1). The percentage of patients achieving improvements in disease activity at Week 24 was greater for sarilumab versus adalimumab among both patients with and without BL NIP, and these differences were larger among patients with BL NIP for all assessments except ACR50 (Figure 2).

Table.

Baseline characteristics

Patients with TJC – SCJ ≥7Mean (SD)Yes (n = 490)No (n = 1622)Duration of RA, years9.1 (8.6)9.7 (8.4)TJC, 0–2821.7 (4.7)14.3 (6.2)SJC, 0–2810.7 (4.3)13.1 (6.0)CRP, mg/L22.7 (27.0)22.9 (24.0)HAQ-DI, 0–31.8 (0.6)1.7 (0.6)DAS28-CRP6.4 (0.7)5.9 (0.9)CDAI46.0 (9.4)40.4 (13.0)Pain VAS72.3 (18.2)67.0 (20.7)

Conclusion:

NIP was prevalent at BL in the patient populations assessed. Among patients with BL NIP, a lower proportion continued to have NIP at Weeks 12 and 24 when treated with sarilumab versus placebo or adalimumab. Patients with and without BL NIP had greater improvements in pain when treated with sarilumab versus adalimumab. The difference in clinical improvement was greater among patients with BL NIP versus without BL NIP for most measures. These trends support the emerging concept that mechanisms other than direct inflammation may contribute to pain in RA, potentially mediated via IL-6 signaling.

References:

[1]Durán J et al.Rheumatology. 2015;54:2166–70

[2]Pollard LC et al.Rheumatology. 2010;49:924–8

Acknowledgments:

Study funding and medical writing support (Joseph Hodgson, PhD, Adelphi Communications Ltd, Macclesfield, UK) provided by Sanofi Genzyme (Cambridge, MA, USA) and Regeneron Pharmaceuticals, Inc. (Tarrytown, NJ, USA) in accordance with GPP3 guidelines.

Disclosure of Interests:

Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Vivian Bykerk: None declared, Yvonne Lee Shareholder of: Cigna-Express Scripts, Grant/research support from: Pfizer, Consultant of: Highland Instruments, Inc., Gregory St John Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., Hubert van Hoogstraten Shareholder of: Sanofi, Employee of: Sanofi, Kerri Ford Shareholder of: Sanofi Genzyme, Employee of: Sanofi Genzyme, Amy Praestgaard Employee of: Sanofi Genzyme, Anthony Sebba Consultant of: Genentech, Gilead, Lilly, Regeneron Pharmaceuticals Inc., Sanofi, Speakers bureau: Lilly, Roche, Sanofi

FRI0108 ASSOCIATION BETWEEN CHANGES IN C-REACTIVE PROTEIN AT WEEK 12 AND PATIENT-REPORTED OUTCOMES AT WEEK 24 WITH SARILUMAB THERAPY ACROSS THREE PIVOTAL PHASE 3 STUDIES

Background:

Evaluation of early response to rheumatoid arthritis (RA) therapy at 12 weeks after initiation is recommended in treatment guidelines. C-reactive protein (CRP) response at 12 weeks on therapy may indicate favorable longer-term patient-reported outcomes (PROs).

Objectives:

To describe the association between CRP response at Week 12 and PROs at Week 24 with sarilumab therapy across three pivotal studies.

Methods:

The analysis included patients with RA who took part in MOBILITY (NCT01061736), TARGET (NCT01709578), or MONARCH (NCT02332590) and were treated with sarilumab 200 mg every 2 weeks (q2w) or adalimumab 40 mg q2w (MONARCH only). Patients who achieved a CRP response at Week 12 (defined as serum CRP ≤3 mg/L) were evaluated for PROs at Week 24. Response for PROs was defined as change from baseline visual analog scale score ≥10 for pain, sleep, and morning stiffness and an increase of ≥4 for FACIT-Fatigue score. Odds ratios (ORs) and 95% confidence intervals (CIs) were generated for the likelihood of achieving PRO responses at Week 24.

Results:

The proportions of patients achieving a CRP response at Week 12 were 78% (MOBILITY), 74% (TARGET), 80% (MONARCH, sarilumab), and 36% (MONARCH, adalimumab). Of these, 71.4% (MOBILITY; OR 3.78, 95% CI 2.31–6.18), 71.5% (TARGET; OR 2.86, 95% CI 1.44–5.65), 79.7% (MONARCH, sarilumab; OR 4.40, 95% CI 2.04–9.47), and 79.7% (MONARCH, adalimumab; OR 2.76, 95% CI 1.36–5.61) reported pain score responses at Week 24. Fatigue responses at Week 24 among Week 12 CRP responders were 66.6% (MOBILITY; OR 2.74, 95% CI 1.69–4.45), 59.9% (TARGET; OR 3.18, 95% CI 1.58–6.42), 73.0% (MONARCH, sarilumab; OR 4.78, 95% CI 2.21–10.33), and 64.1% (MONARCH, adalimumab; OR 1.64, 95% CI 0.88–3.06). Sleep was evaluated in MOBILITY only, and 58.2% of those achieving Week 12 CRP responses reported sleep score responses at Week 24 (OR 3.51, 95% CI 2.10–5.87). Morning stiffness responses (evaluated in TARGET and MONARCH only) at Week 24 among patients with Week 12 CRP responses were 71.5% (TARGET; OR 3.70, 95% CI 1.86–7.39), 81.1% (MONARCH, sarilumab; OR 5.36, 95% CI 2.47–11.63), and 75.0% (MONARCH, adalimumab; OR 2.42, 95% CI 1.24–4.72).

Conclusion:

Achievement of a CRP response at Week 12 in patients with RA treated with sarilumab 200 mg q2w or adalimumab 40 mg q2w was associated with improvements at Week 24 in PROs for pain, fatigue, sleep, and morning stiffness. Among patients with RA, CRP responses at 12 weeks on treatment predict favorable longer-term PRO improvements.

Acknowledgments:

Study funding was provided by Sanofi Genzyme (Cambridge, USA) and Regeneron Pharmaceuticals, Inc. (Tarrytown, USA). Medical writing support (Tracey Lonergan, Adelphi Communications Ltd, Macclesfield, UK) was provided by Sanofi Genzyme and Regeneron Pharmaceuticals, Inc. in accordance with Good Publication Practice (GPP3) guidelines.

Disclosure of Interests:

John Tesser Consultant of: Sanofi/Regeneron, Speakers bureau: Sanofi/Regeneron, Grace C. Wright Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Exagen, Eli Lilly, Myriad Autoimmune, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi Genzyme, UCB, Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Exagen, Eli Lilly, Myriad Autoimmune, Novartis, Regeneron Pharmaceuticals, Inc., Sanofi Genzyme, UCB, Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Jeff Kaine Speakers bureau: Eli Lilly, Merck, Regeneron Pharmaceuticals, Inc., Sanofi, Karina Maslova Shareholder of: Sanofi Genzyme, Employee of: Sanofi Genzyme, Gregory St John Shareholder of: Regeneron Pharmaceuticals, Inc., Employee of: Regeneron Pharmaceuticals, Inc., Kerri Ford Shareholder of: Sanofi Genzyme, Employee of: Sanofi Genzyme, Amy Praestgaard Employee of: Sanofi Genzyme, Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB

Understanding the association between self-reported poor oral health and exposure to adverse childhood experiences: a retrospective study

Background

Adverse childhood experiences, including physical, sexual or emotional abuse, can have detrimental impacts on child and adult health. However, little research has explored the impact that such early life experiences have on oral health. This study examines whether experiencing adverse childhood experiences before the age of 18 years is associated with self-reported poor dental health in later life.

Methods

Using stratified random probability sampling, a household survey (N = 5307; age range 18–69 years) was conducted in the South of England (Hertfordshire, Luton and Northamptonshire). Data were collected at participants’ homes using face-to-face interviews. Measures included exposure to nine adverse childhood experiences, and two dental outcomes: tooth loss (> 8 teeth lost due to dental caries or damage) and missing or filled teeth (direct or indirect restorations; > 12 missing or filled teeth).

Results

Strong associations were found between exposure to childhood adversity and poor dental health. The prevalence of tooth loss was significantly higher (8.3%) in those with 4+ adverse childhood experiences compared to those who had experienced none (5.0%; p < 0.05). A similar relationship was found for levels of missing or filled teeth (13.4%, 4+ adverse childhood experiences; 8.1%, none; p < 0.001). Exposure to 4+ adverse childhood experiences was associated with a higher level of tooth loss and restorations at any age, compared to individuals who had not experienced adversity. Demographically adjusted means for tooth loss increased with adverse childhood experience count in all age groups, rising from 1.0% (18–29 years) and 13.0% (60–69 years) in those with none, to 3.0% and 26.0%, respectively in those reporting 4+.

Conclusions

Exposure to childhood adversity could be an important predictive factor for poor dental health. As oral health is an important part of a child’s overall health status, approaches that seek to improve dental health across the life-course should start with safe and nurturing childhoods free from abuse and neglect. Given the growing role that dental professionals have in identifying violence and abuse, it seems appropriate to raise awareness in the field of dentistry of the potential for individuals to have suffered adverse childhood experiences, and the mechanisms linking childhood adversity to poor dental health.

Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: a systematic review and meta-analysis

BACKGROUND

An increasing number of studies are identifying associations between adverse childhood experiences (ACEs) and ill health throughout the life course. We aimed to calculate the proportions of major risk factors for and causes of ill health that are attributable to one or multiple types of ACE and the associated financial costs.

METHODS

In this systematic review and meta-analysis, we searched for studies in which risk data in individuals with ACEs were compared with these data in those without ACEs. We searched six electronic databases (MEDLINE, CINAHL, PsycINFO, Applied Social Sciences Index and Abstracts, Criminal Justice Databases, and the Education Resources Information Center) for quantitative studies published between Jan 1, 1990, and July 11, 2018, that reported risks of health-related behaviours and causes of ill health in adults that were associated with cumulative measures of ACEs (ie, number of ACEs). We included studies in adults in populations that did not have a high risk of ACEs, that had sample sizes of at least 1000 people, and that provided ACE prevalence data. We calculated the pooled RR for risk factors (harmful alcohol use, illicit drug use, smoking, and obesity) and causes of ill health (cancer, diabetes, cardiovascular disease, respiratory disease, anxiety, and depression) associated with ACEs. RRs were used to estimate the population-attributable fractions (PAFs) of risk attributable to ACEs and the disability-adjusted life-years (DALYs) and financial costs associated with ACEs. This study was prospectively registered in PROSPERO (CRD42018090356).

FINDINGS

Of 4387 unique articles found following our initial search, after review of the titles (and abstracts, when the title was relevant), we assessed 880 (20%) full-text articles. We considered 221 (25%) full-text articles for inclusion, of which 23 (10%) articles met all selection criteria for our meta-analysis. We found a pooled prevalence of 23·5% of individuals (95% CI 18·7-28·5) with one ACE and 18·7% (14·7-23·2) with two or more ACEs in Europe (from ten studies) and of 23·4% of individuals (22·0-24·8) with one ACE and 35·0% (31·6-38·4) with two or more ACEs in north America (from nine studies). Illicit drug use had the highest PAFs associated with ACEs of all the risk factors assessed in both regions (34·1% in Europe; 41·1% in north America). In both regions, PAFs of causes of ill health were highest for mental illness outcomes: ACEs were attributed to about 30% of cases of anxiety and 40% of cases of depression in north America and more than a quarter of both conditions in Europe. Costs of cardiovascular disease attributable to ACEs were substantially higher than for most other causes of ill health because of higher DALYs for this condition. Total annual costs attributable to ACEs were estimated to be US$581 billion in Europe and $748 billion in north America. More than 75% of these costs arose in individuals with two or more ACEs.

INTERPRETATION

Millions of adults across Europe and north America live with a legacy of ACEs. Our findings suggest that a 10% reduction in ACE prevalence could equate to annual savings of 3 million DALYs or $105 billion. Programmes to prevent ACEs and moderate their effects are available. Rebalancing expenditure towards ensuring safe and nurturing childhoods would be economically beneficial and relieve pressures on health-care systems.

FUNDING

World Health Organization Regional Office for Europe.

Low-fidelity Paediatric Surgical Simulation: Description of Models in Low-Resource Settings

BACKGROUND

Surgical simulation is an important aspect of competency-based training. Recent trends in paediatric surgical simulations have migrated towards high-fidelity simulation with advanced technology resulting in models which are expensive and largely inaccessible in low- and middle-income countries.

METHODS

This article describes four wet simulation models of common surgical procedures in paediatric population created with animal tissue from local abattoir. The models are designed to provide a framework for others to make the models and benefit from the training opportunity they provide especially in low-middle-income countries.

RESULTS

The models created in the wet laboratory are neonatal bowel anastomosis, duodenoduodenostomy for discrepancy anastomosis, gastrostomy and pyeloplasty. These models are easily reproducible in resource-challenged healthcare setting as they are low cost, utilise locally available resources and require only a basic set of surgical instruments with which to perform the procedures.

CONCLUSION

These models provide locally accessible material for sustainable training programmes which are fundamental in developing safe and affordable surgical care worldwide.

The evidence base for routine enquiry into adverse childhood experiences: A scoping review

BACKGROUND

Exposure to adverse childhood experiences (ACEs; e.g., maltreatment, household dysfunction) is associated with a multiplicity of negative outcomes throughout the life course. Consequently, increasing interest is being paid to the application of routine enquiry for ACEs to enable identification and direct interventions to mitigate their harms.

OBJECTIVE

To explore the evidence base for retrospective routine enquiry in adults for ACEs, including feasibility and acceptability amongst practitioners, service user acceptability and outcomes from implementation.

METHODS

A scoping review of the literature was conducted, drawing upon three databases (CINAHL, MEDLINE, PsycINFO) and manual searching and citation tracking. Searches included studies published from 1997 until end of April 2018 examining enquiry into ACEs, or the feasibility/acceptability of such enquiry across any setting. All included studies presented empirical findings, with studies focusing on screening for current adversities excluded.

RESULTS

Searches retrieved 380 articles, of which 15 met the eligibility criteria. A narrative approach to synthesize the data was utilized. Four studies examined practitioner feasibility and/or acceptability of enquiry, three reported service user acceptability and six studies implemented routine ACE enquiry (not mutually exclusive categories). Further, eight studies explored current practice and practitioner attitudes towards ACE enquiry.

CONCLUSIONS

Limited literature was found providing evidence for outcomes from enquiry. No studies examined impacts on service user health or service utilization. Few studies explored feasibility or acceptability to inform the application of routine ACE enquiry. The implementation of routine ACE enquiry therefore needs careful consideration. Focus should remain on evaluating developing models of ACE enquiry to advance understanding of its impact.

Ideal, expected and perceived descriptive norm drunkenness in UK nightlife environments: a cross-sectional study

Background

Drunkenness is common in nightlife environments and studies suggest it can be considered both desirable and normal by nightlife users. We aimed to compare UK nightlife users’ ideal levels of drunkenness to their expected drunkenness on a night out and their perceptions of descriptive nightlife norms.

Methods

A cross-sectional survey with nightlife patrons (n = 408, aged 18–35) in three cities. Using a scale from 1 (completely sober) to 10 (very drunk), participants rated: personal drunkenness at survey; expected drunkenness on leaving nightlife; perceived descriptive drunkenness norm in the city’s nightlife; and ideal personal drunkenness. Analyses were limited to those who had or were intending to consume alcohol.

Results

Almost half of participants (46.8%) expected to get drunker than their reported ideal level on the night of survey, rising to four fifths of those with the highest levels of expected drunkenness. 77.9% rated typical nightlife drunkenness ≥8 but only 40.9% expected to reach this level themselves and only 23.1% reported their ideal drunkenness as ≥8. Higher expected drunkenness was associated with higher ideal drunkenness, higher perceived drunkenness norm and later expected home time.

Conclusions

Nightlife users’ perceptions of typical drunkenness in nightlife settings may be elevated and many of the heaviest drinkers are likely to drink beyond their ideal level of drunkenness. Findings can support emerging work to address cultures of intoxication in nightlife environments and suggest that interventions to correct misperceptions of normal levels of nightlife drunkenness may be of benefit.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6802-5) contains supplementary material, which is available to authorized users.

Associations between childhood deaths and adverse childhood experiences: An audit of data from a child death overview panel

BACKGROUND

Despite strong associations between adverse childhood experiences (ACEs) and poor health, few studies have examined the cumulative impact of ACEs on causes of childhood mortality.

METHODS

This study explored if data routinely collected by child death overview panels (CDOPs) could be used to measure ACE exposure and examined associations between ACEs and child death categories. Data covering four years (2012-2016) of cases from a CDOP in North West England were examined.

RESULTS

Of 489 cases, 20% were identified as having ≥4 ACEs. Deaths of children with ≥4 ACEs were 22.26 (5.72-86.59) times more likely (than those with 0 ACEs) to be classified as 'avoidable and non-natural' causes (e.g., injury, abuse, suicide; compared with 'genetic and medical conditions'). Such children were also 3.44 (1.75-6.73) times more likely to have their deaths classified as 'chronic and acute conditions'.

CONCLUSIONS

This study evidences that a history of ACEs can be compiled from CDOP records. Measurements of ACE prevalence in retrospective studies will miss individuals who died in childhood and may underestimate the impacts of ACEs on lifetime health. Strong associations between ACEs and deaths from 'chronic and acute conditions' suggest that ACEs may be important factors in child deaths in addition to those classified as 'avoidable and non-natural'. Results add to an already compelling case for ACE prevention in the general population and families affected by child health problems. Broader use of routinely collected child death records could play an important role in improving multi-agency awareness of ACEs and their negative health and mortality risks as well in the development of ACE informed responses.

Does adult alcohol consumption combine with adverse childhood experiences to increase involvement in violence in men and women? A cross-sectional study in England and Wales

OBJECTIVES

To examine if, and to what extent, a history of adverse childhood experiences (ACEs) combines with adult alcohol consumption to predict recent violence perpetration and victimisation.

DESIGN

Representative face-to-face survey (n=12 669) delivered using computer-assisted personal interviewing and self-interviewing.

SETTING

Domiciles of individuals living in England and Wales.

PARTICIPANTS

Individuals aged 18-69 years resident within randomly selected locations. 12 669 surveys were completed with participants within our defined age range.

MAIN OUTCOME MEASURES

Alcohol consumption was measured using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and childhood adversity using the short ACEs tool. Violence was measured using questions on perpetration and victimisation in the last 12 months.

RESULTS

Compliance was 55.7%. There were strong positive relationships between numbers of ACEs and recent violence perpetration and victimisation in both sexes. Recent violence was also strongly related to positive AUDIT-C (≥5) scores. In males, heavier drinking and ≥4ACEs had a strong multiplicative relationship with adjusted prevalence of recent violent perpetration rising from 1.3% (95% CIs 0.9% to 1.9%; 0 ACEs, negative AUDIT-C) to 3.6% (95% CIs 2.7% to 4.9%; 0 ACEs, positive AUDIT-C) and 8.5% (95% CI 5.6% to 12.7%; ≥4ACEs, negative AUDIT-C) to 28.3% (95% CI 22.5% to 34.8%; ≥4ACEs, positive AUDIT-C). In both sexes, violence perpetration and victimisation reduced with age independently of ACE count and AUDIT-C status. The combination of young age (18-29 years), ≥4ACEs and positive AUDIT-C resulted in the highest adjusted prevalence for both perpetration and victimisation in males (61.9%, 64.9%) and females (24.1%, 27.2%).

CONCLUSIONS

Those suffering multiple adverse experiences in childhood are also more likely to be heavier alcohol users. Especially for males, this combination results in substantially increased risks of violence. Addressing ACEs and heavy drinking together is rarely a feature of public health policy, but a combined approach may help reduce the vast costs associated with both.

Measuring the relationships between adverse childhood experiences and educational and employment success in England and Wales: findings from a retrospective study

OBJECTIVES

Educational and employment outcomes are critical elements in determining the life course of individuals, yet through health and other mechanisms, those who suffer adverse childhood experiences (ACEs) may experience barriers to achieve in these domains. This study examines the association between ACEs and poor educational outcomes, before considering the impact of ACEs and education on employment in adulthood.

STUDY DESIGN

Retrospective cross-sectional surveys were conducted in England and Wales using a random stratified sampling methodology.

METHODS

During face-to-face household interviews (n = 2881), data were collected on demographic factors, ACEs, self-rated childhood affluence, the highest qualification level attained and the current employment status.

RESULTS

While respondents with ≥4 ACEs were significantly more likely to have no formal qualifications (adjusted odds ratio [AOR] = 2.18; P < 0.001), among those who did achieve secondary level qualifications, the presence of ACEs did not further impact subsequent likelihood of going on to attain college or higher qualifications. However, results suggest a persisting independent impact of high (≥4) ACEs, which were found to be significantly associated with both current unemployment (AOR = 2.52, P < 0.001) and long-term sickness and disability (AOR = 3.94, P < 0.001). Modelled levels of not being in employment ranged from as little as 3% among those with 0 or 1 ACE and higher qualifications to 62% among those with no qualifications and ≥4 ACEs (adjusted for age, gender and childhood affluence effects).

CONCLUSIONS

Compulsory education may play a pivotal role in mitigating the effects of adversity, supporting the case for approaches within schools that build resilience and tackle educational inequalities. However, adults with ACEs should not be overlooked and efforts should be considered to support them in achieving meaningful employment.

Drink Less Enjoy More: effects of a multi-component intervention on improving adherence to, and knowledge of, alcohol legislation in a UK nightlife setting

AIMS

To estimate the association between implementation of a community-based multi-component intervention (Drink Less Enjoy More) and sales of alcohol to pseudo-intoxicated patrons and nightlife patron awareness of associated legislation.

DESIGN

Cross-sectional pre-intervention and follow-up measurements, including alcohol test purchases (using pseudo-intoxicated patrons) in licensed premises (stratified random sample; 2013, 2015) and a survey with nightlife patrons (convenience sample; 2014, 2015).

SETTING

One UK municipality with a large night-time economy.

PARTICIPANTS

Licensed premises (pre = 73; follow-up = 100); nightlife patrons (pre = 214; follow-up = 202).

INTERVENTION

The Drink Less Enjoy More intervention included three interacting components: community mobilization and awareness-raising; responsible bar server training; and active law enforcement of existing legislation prohibiting sales of alcohol to, and purchasing of alcohol for, a person who appears to be alcohol intoxicated: 'intoxicated', herein for economy.

MEASUREMENTS

The primary outcomes were alcohol service refusal to pseudo-intoxicated patrons and nightlife patron knowledge of alcohol legislation (illegal to sell alcohol to, and purchase alcohol for, intoxicated people), adjusted for potential confounders including characteristics of the area, venue, test purchase and nightlife patron.

FINDINGS

Pre-intervention, 16.4% of alcohol sales were refused, compared with 74.0% at follow-up (P < 0.001). In adjusted analyses, the odds of service refusal were higher at follow-up [adjusted odds ratio (aOR) = 14.63, P < 0.001]. Service refusal was also associated with server gender and patron drunkenness within the venue. Among drinkers, accurate awareness of alcohol legislation was higher at follow-up (sales: pre = 44.5%; follow-up = 66.0%; P < 0.001/purchase: pre = 32.5%; follow-up = 56.0%; P < 0.001). In adjusted analyses, knowledge of legislation was higher at follow-up (sales: aOR = 2.73, P < 0.001; purchasing: aOR = 2.73, P < 0.001). Knowledge of legislation was also associated with participant age (purchasing) and expectations of intoxication (sales).

CONCLUSION

A community-based multi-component intervention concerning alcohol sales legislation in the United Kingdom (UK) was associated with a reduction in sales of alcohol to pseudo-intoxicated patrons in on-licensed premises in a UK nightlife setting and an improvement in nightlife patron awareness of associated legislation.

Adverse childhood experiences and sources of childhood resilience: a retrospective study of their combined relationships with child health and educational attendance

BACKGROUND

Adverse childhood experiences (ACEs) including maltreatment and exposure to household stressors can impact the health of children. Community factors that provide support, friendship and opportunities for development may build children's resilience and protect them against some harmful impacts of ACEs. We examine if a history of ACEs is associated with poor childhood health and school attendance and the extent to which such outcomes are counteracted by community resilience assets.

METHODS

A national (Wales) cross-sectional retrospective survey (n = 2452) using a stratified random probability sampling methodology and including a boost sample (n = 471) of Welsh speakers. Data collection used face-to-face interviews at participants' places of residence. Outcome measures were self-reported poor childhood health, specific conditions (asthma, allergies, headaches, digestive disorders) and school absenteeism.

RESULTS

Prevalence of each common childhood condition, poor childhood health and school absenteeism increased with number of ACEs reported. Childhood community resilience assets (being treated fairly, supportive childhood friends, being given opportunities to use your abilities, access to a trusted adult and having someone to look up to) were independently linked to better outcomes. In those with ≥4 ACEs the presence of all significant resilience assets (vs none) reduced adjusted prevalence of poor childhood health from 59.8 to 21.3%.

CONCLUSIONS

Better prevention of ACEs through the combined actions of public services may reduce levels of common childhood conditions, improve school attendance and help alleviate pressures on public services. Whilst the eradication of ACEs remains unlikely, actions to strengthen community resilience assets may partially offset their immediate harms.

The impact of adverse childhood experiences on health service use across the life course using a retrospective cohort study

Objectives

The lifelong health impacts of adverse childhood experiences are increasingly being identified, including earlier and more frequent development of non-communicable disease. Our aim was to examine whether adverse childhood experiences are related to increased use of primary, emergency and in-patient care and at what ages such impact is apparent.

Methods

Household surveys were undertaken in 2015 with 7414 adults resident in Wales and England using random probability stratified sampling (age range 18–69 years). Nine adverse childhood experiences (covering childhood abuse and household stressors) and three types of health care use in the last 12 months were assessed: number of general practice (GP) visits, emergency department (ED) attendances and nights spent in hospital.

Results

Levels of use increased with increasing numbers of adverse childhood experiences experienced. Compared to those with no adverse childhood experiences, odds (±95% CIs) of frequent GP use (≥6 visits), any ED attendance or any overnight hospital stay were 2.34 (1.88–2.92), 2.32 (1.90–2.83) and 2.67 (2.06–3.47) in those with ≥ 4 adverse childhood experiences. Differences were independent of socio-economic measures of deprivation and other demographics. Higher health care use in those with ≥ 4 adverse childhood experiences (compared with no adverse childhood experiences) was evident at 18–29 years of age and continued through to 50–59 years. Demographically adjusted means for ED attendance rose from 12.2% of 18-29 year olds with no adverse childhood experiences to 28.8% of those with ≥ 4 adverse childhood experiences. At 60–69 years, only overnight hospital stay was significant (9.8% vs. 25.0%).

Conclusions

Along with the acute impacts of adverse childhood experiences on child health, a life course perspective provides a compelling case for investing in safe and nurturing childhoods. Disproportionate health expenditure in later life might be reduced through childhood interventions to prevent adverse childhood experiences.

Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences - a retrospective study on adult health-harming behaviours and mental well-being

BACKGROUND

Adverse childhood experiences (ACEs) including child abuse and household problems (e.g. domestic violence) increase risks of poor health and mental well-being in adulthood. Factors such as having access to a trusted adult as a child may impart resilience against developing such negative outcomes. How much childhood adversity is mitigated by such resilience is poorly quantified. Here we test if access to a trusted adult in childhood is associated with reduced impacts of ACEs on adoption of health-harming behaviours and lower mental well-being in adults.

METHODS

Cross-sectional, face-to-face household surveys (aged 18-69 years, February-September 2015) examining ACEs suffered, always available adult (AAA) support from someone you trust in childhood and current diet, smoking, alcohol consumption and mental well-being were undertaken in four UK regions. Sampling used stratified random probability methods (n = 7,047). Analyses used chi squared, binary and multinomial logistic regression.

RESULTS

Adult prevalence of poor diet, daily smoking and heavier alcohol consumption increased with ACE count and decreased with AAA support in childhood. Prevalence of having any two such behaviours increased from 1.8% (0 ACEs, AAA support, most affluent quintile of residence) to 21.5% (≥4 ACEs, lacking AAA support, most deprived quintile). However, the increase was reduced to 7.1% with AAA support (≥4 ACEs, most deprived quintile). Lower mental well-being was 3.27 (95% CIs, 2.16-4.96) times more likely with ≥4 ACEs and AAA support from someone you trust in childhood (vs. 0 ACE, with AAA support) increasing to 8.32 (95% CIs, 6.53-10.61) times more likely with ≥4 ACEs but without AAA support in childhood. Multiple health-harming behaviours combined with lower mental well-being rose dramatically with ACE count and lack of AAA support in childhood (adjusted odds ratio 32.01, 95% CIs 18.31-55.98, ≥4 ACEs, without AAA support vs. 0 ACEs, with AAA support).

CONCLUSIONS

Adverse childhood experiences negatively impact mental and physical health across the life-course. Such impacts may be substantively mitigated by always having support from an adult you trust in childhood. Developing resilience in children as well as reducing childhood adversity are critical if low mental well-being, health-harming behaviours and their combined contribution to non-communicable disease are to be reduced.

Gastroschisis: Bellwether for neonatal surgery capacity in low resource settings?

INTRODUCTION

Economic disadvantage may adversely influence the outcomes of infants with gastroschisis (GS). Gastroschisis International (GiT) is a network of seven paediatric surgical centres, spanning two continents, evaluating GS treatment and outcomes.

MATERIAL AND METHODS

A 2-year retrospective review of GS infants at GiT centres. Primary outcome was mortality. Sites were classified into high, middle and low income country (HIC, MIC, and LIC). MIC and LIC were sometimes combined for analysis (LMIC). Disability adjusted life years (DALYs) were calculated and centres with the highest mortality underwent a needs assessment.

RESULTS

Mortality was higher in the LICs and LMICs: 100% in Uganda and Cote d'Ivoire, 75% in Nigeria and 60% in Malawi. 29% and 0% mortality was reported in South Africa and the UK, respectively. Septicaemia was the commonest cause of death. Averted and non-avertable DALYs were nil in Uganda and Cote d'Ivoire (no survivors). In the UK (100% survival) averted DALYs (met need) was highest, representing death and disability prevented by surgical intervention. Performance improvement measures were agreed: a prospectively maintained GS register; clarification of the key team members of a GS team and management pathway.

CONCLUSIONS

We propose the use of GS as a bellwether condition for assessing institutional capacity to deliver newborn surgical care. Early access to care, efficient multidisciplinary team working, appropriate resuscitation, avoidance of abdominal compartment syndrome, stabilization prior to formal closure and proactive nutritional interventions may reduce GS-associated burden of disease in low resource settings.