What are the public health implications of the life course perspective?

Clinical decisions in fetal-neonatal neurology I. reproductive and pregnancy health influence the neural exposome over multiple generations

Interdisciplinary fetal neonatal neurology (FNN) training requires integration of reproductive health factors into evaluations of the maternal-placental-fetal (MPF) triad, neonate, and child over the first 1000 days. Serial events that occur before one or multiple pregnancies impact successive generations. A maternal-child dyad history highlights this continuity of health risk, beginning with a maternal grandmother's pregnancy. Her daughter was born preterm and later experienced polycystic ovarian syndrome further complicated by cognitive and mental health disorders. Medical problems during her pregnancy contributed to MPF triad diseases that resulted in her son's extreme prematurity. Postpartum maternal death from the complications of diabetic ketoacidosis and her child's severe global neurodevelopmental delay were adverse mother-child outcomes. A horizontal/vertical diagnostic approach to reach shared clinical decisions during FNN training requires perspectives of a dynamic neural exposome. Career-long learning is then strengthened by continued interactions from al stakeholders. Developmental origins theory applied to neuroplasticity principles help interpret phenotypic expressions as dynamic gene-environment interactions across a person's lifetime. Debiasing strategies applied to the cognitive process reduce bias to preserve therapeutic and prognostic accuracy. Social determinants of health are essential components of this strategy to be initiated during FNN training. Reduction of the global burden of neurologic disorders requires applying the positive effects from reproductive and pregnancy exposomes that will benefit the neural exposome across the lifespan.

Clinical decisions in fetal-neonatal neurology II: Gene-environment expression over the first 1000 days presenting as "four great neurological syndromes"

Interdisciplinary fetal-neonatal neurology (FNN) training considers a woman's reproductive and pregnancy health histories when assessing the "four great neonatal neurological syndromes". This maternal-child dyad exemplifies the symptomatic neonatal minority, compared with the silent majority of healthy children who experience preclinical diseases with variable expressions over the first 1000 days. Healthy maternal reports with reassuring fetal surveillance testing preceded signs of fetal distress during parturition. An encephalopathic neonate with seizures later exhibited childhood autistic spectrum behaviors and intractable epilepsy correlated with identified genetic biomarkers. A systems biology approach to etiopathogenesis guides the diagnostic process to interpret phenotypic form and function. Evolving gene-environment interactions expressed by changing phenotypes reflect a dynamic neural exposome influenced by reproductive and pregnancy health. This strategy considers critical/sensitive periods of neuroplasticity beyond two years of life to encompass childhood and adolescence. Career-long FNN experiences reenforce earlier training to strengthen the cognitive process and minimize cognitive biases when assessing children or adults. Prioritizing social determinants of healthcare for persons with neurologic disorders will help mitigate the global burden of brain diseases for all women and children.

A Link between Prenatal Stage of Life during the Great Chinese Famine and Subsequent Depressive Symptoms among Middle-Aged and Older Adults

Prenatal malnutrition may increase the risk of depressive symptoms in adulthood. This study investigated the association between prenatal exposure to malnutrition with risk of depressive symptoms in middle-aged and older adults using the Chinese Great Famine of 1959-1961 as a natural experiment. Data were obtained from the China Health and Retirement Longitudinal Study baseline survey (2011). A total of 5391 individuals born from 1956 to 1965 were included in the study. Depressive symptoms were ascertained via the Center for Epidemiological Studies Depression Scale short form. Famine severity was measured using the cohort size shrinkage index. Difference-in-differences models were used to explore the association between prenatal famine exposure and later-life depressive symptoms. Compared with the post-famine cohort (1963-1965), famine cohorts (1959-1962) were 4.74 times (95% CI = 1.28-8.20) as likely to develop depressive symptoms. The stratified analysis found that prenatal exposure to famine was associated with depressive symptoms in rural residents but not those living in urban areas. In rural females, prenatal malnutrition was associated with a higher risk of depressive symptoms. However, there was no significant association between prenatal malnutrition and depressive symptoms in rural males. Our results indicated that prenatal malnutrition may contribute to a higher risk for depressive symptoms in later life among female rural residents.

Exploring the Needs and Expectations of Expectant and New Parents for an mHealth Application to Support the First 1000 Days of Life: Steps toward a Co-Design Approach

To improve maternal and child health, it is essential to adhere to health-promoting and preventive measures. However, reliable information as well as effective tools are not easy to identify in this field. Our cross-sectional study investigated the needs and expectations of expectant and new mothers and fathers as potential primary users of a hypothetical application supporting the first 1000 days of life. Between May and August 2022, we recruited expectant and new parents by administering an 83-item 5-point Likert scale questionnaire related to the content, functionalities, and technical features of the hypothetical app. We stratified responses using sociodemographic characteristics and then performed ward hierarchical clustering. The 94 women and 69 men involved in our study generally agreed with the proposed content, but expressed low interest in certain app functionalities or features, including those related to the interaction mechanism and interactivity. Women were generally more demanding than men. Our findings, resulting from the engagement of end-users, may be useful for designers and technology providers to implement mHealth solutions that, in addition to conveying reliable information, are tailored to the needs and preferences of end-users in the first 1000 days of life.

What do hospital-based health professionals need and expect from an mHealth app to support the first 1000 days of life? Results from a cross sectional study

BACKGROUND

Several attempts have been made to introduce mHealth solutions to support maternal, newborn, and child health (MNCH). However, most of the available apps do not meet the needs of end-users, underscoring the urgency of involving them in the co-design of telehealth interventions.

OBJECTIVE

With this in mind, we investigated the needs and expectations of hospital-based health professionals (i.e., secondary users) providing care to pregnant women and new mothers with their babies for a hypothetical mHealth app to support the first 1000 days of life.

METHODS

From November 2021 to March 2022, we surveyed health professionals using a questionnaire that explored the perceived importance of specific content, functionalities, and technical features of the proposed app. We also collected sociodemographic information from secondary users. We performed descriptive analysis and then used Ward hierarchical clustering method to classify respondents according to their response patterns.

RESULTS

We recorded the needs and expectations of 145 hospital-based health professionals from obstetrics/gynecology, nursery/neonatology, and pediatrics. We found general agreement with the proposed content of the app, particularly general information about health during pregnancy (92%) and potential risky infections during pregnancy (91%). Three clusters emerged from the analysis, with the high and medium demanding clusters rating the importance of app content and technical features as very high and high, respectively, while low demanding cluster expressing more skepticism, especially about some of the proposed functionalities of the app.

CONCLUSIONS

Assessing the needs and expectations of end-users is an essential process for developing tailored and effective mHealth solutions. This study has shown that hospital-based health professionals generally recognize the value of the proposed app, suggesting their propensity to integrate such a telehealth solution into mainstream clinical practice.

A conceptual framework for selecting appropriate populations for public health interventions

This article suggests a conceptual framework for choice of target populations for public health interventions. In short, who should benefit? Taking the seminal work of Geoffrey Rose on "individuals at risk" versus the "whole population approach" as a point of departure, we explore later contributions. Frohlich and Potvin introduced the notion of "vulnerable populations" applying relevant social determinants as the defining selection criterion. Other interventions focus on a "physical space" (spatial demarcations) such as a neighborhood as a means to define intervention populations. As an addition to these criteria, we suggest that the life-course perspective entails an alternative means of selecting target populations based on a "temporal" perspective. A focus on the various age phases ranging from fetal life and infancy to old age may guide selection of population segments for targeted public health interventions. Each of the selection criteria has advantages and disadvantages when used for primary, secondary, or tertiary prevention. Thus, the conceptual framework may guide informed decisions in public health planning and research regarding precision prevention versus various approaches to complex community-based interventions.

Exploring the impact of health worker strikes on maternal and child health in a Kenyan county

Background

Studies of the impact of health care workers’ strikes tend to look at facility-level activity rather than populations, with evidence from low and middle-income countries relatively sparse. This study explored the effect of national strikes on maternal and child health. It looked at the impact on health system activity in both public and non-public sectors (e.g. private, faith-based), on health promotion investments like immunisation, and on disease detection like post-partum haemorrhage (PPH). A 100 day doctors’ strike started in December 2016, a 150 day nurses strike from June 2017 and then the clinical officers for 21 days that September.

Methods

Time series descriptive analysis of attendance data from the Kenyan Health Management Information System (public, non-public sector facilities). The setting was Kilifi, a coastal county in Kenya with a population of about 1.5 million.

Results

Along the care pathway from antenatal, postnatal and out-patient child health clinics, activity levels dropped markedly in the public sector with only partial compensatory increases in non-public sector activity. The number of fully immunised children fell during the nurses strike as did women seen with PPH during all strikes. These health care strikes caused significant adverse health impacts at the time and potentially inter-generationally as exemplified by the fall in antenatal haematinics supplementation and syphilis testing. Some post-strike ‘’catch-up” activity occurred, however this may have been too late in some instances.

Conclusions

Policy-makers at national and county level need to ensure population health is protected at times of strikes and ideally resolve disputes without such action. Not to do so risks major negative effects on maternal and child health. Increased use of the non-public health sector could be done by the authorities in mitigation should strikes occur again.

Early-life maternal attachment and risky health behaviours in adolescence: findings from the United Kingdom Millennium Cohort Study

Background

Early uptake of multiple risky behaviours during adolescence, such as substance use, antisocial and sexual behaviours, can lead to poor health outcomes without timely interventions. This study investigated how early-life maternal attachment, or emotional bonds between mothers and infants, influenced later risky behaviours in adolescence alongside other potential explanatory pathways using the United Kingdom Millennium Cohort Study.

Methods

Total maternal attachment scores measured at 9 months using the Condon (1998) Maternal Postnatal Attachment Scale compared higher and lower attachment, where mothers in the lowest 10th percentile represented lower attachment. Multiple risky behaviours, defined as two or more risky behaviours (including smoking cigarettes, vaping, alcohol consumption, illegal drug use, antisocial behaviour, criminal engagement, unsafe sex, and gambling), were scored from 0 to 8 at age 17. Five multivariate logistic regression models examined associations between maternal attachment and multiple risky behaviours among Millennium Cohort Study members (n = 7796). Mediation analysis sequentially adjusted for blocks of explanatory mechanisms, including low attachment mechanisms (multiple births, infant prematurity, sex, breastfeeding, unplanned pregnancy and maternal age at birth), maternal depression, and social inequalities (single-parent status, socioeconomic circumstance by maternal education and household income) at 9 months and poor adolescent mental health at 14 years.

Results

Children of mothers with lower maternal attachment at 9 months had 23% increased odds of multiple risky behaviours at 17 years (OR: 1.23, 95% CI: 1.00–1.50) in the unadjusted baseline model. All five explanatory blocks attenuated baseline odds. Low attachment mechanisms attenuated 13%, social inequalities 17%, and poor mental health 17%. Maternal depression attenuated the highest proportion (26%) after fully adjusting for all factors (30%).

Conclusions

Lower maternal attachment in early life predicted increased adolescent multiple risky behaviours. Almost a third of the excess risk was attributable to child, maternal and socioeconomic factors, with over a quarter explained by maternal depression. Recognising the influence of early-life risk factors on adolescent health could innovate current policies and interventions addressing multiple risky behaviour uptake affecting health inequalities across the life course.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12141-5.

Neurologic Sequelae Associated with Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy (HDP) contribute to adverse gene-environment interactions prior to conception and continue throughout pregnancy. Embryonic/fetal brain disorders occur from interactions between genetic susceptibilities interacting with acquired diseases or conditions affecting the maternal/placental fetal (MPF) triad. Trimester-specific pathophysiological mechanisms, such as maternal immune activation and ischemic placental syndrome, contribute to adverse peripartum, neonatal and childhood outcomes. Two diagnostic approaches provide timelier diagnoses over the first 1000 days from conception until two years of age. Horizontal analyses assess the maturation of the triad, neonate and child. Vertical analyses consider systems-biology from genetic, molecular, cellular, tissue through organ networks during each developmental niche. Disease expressions associated with HDP have cumulative adverse effects across the lifespan when subjected to subsequent adverse events. Critical/sensitive periods of developmental neuroplasticity over the first 1000 days are more likely to result in permanent sequelae. Novel diagnostic approaches, beginning during pre-conception, will facilitate the development of effective preventive, rescue and reparative neurotherapeutic strategies in response to HDP-related trimester-specific disease pathways. Public health policies require the inclusion of women's health advocacy during and beyond their reproductive years to reduce sequelae experienced by mothers and their offspring. A lower global burden of neurologic disease from HDP will benefit future generations.

"The First Thousand Days" Define a Fetal/Neonatal Neurology Program

Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.

Health literacy meets the life-course perspective: towards a conceptual framework

This paper presents a novel conceptual framework combining the concepts of health literacy and life-course to guide public health planning and research. Health literacy is a key competence that enables individuals to navigate health-care systems and health promotion activities. The life-course perspective places emphasis on how disease risk accumulates along the life trajectory from fetal life onwards, and how it can even pass from one generation to the next. Our conceptual framework illustrates how different domains of health literacy are required, and how the unequal distribution of health literacy may be influenced by social determinants at different times in the life-course. Thus, it is essential to disaggregate health literacy into sub-themes and analyse them as they unfold in a long-term life-course perspective. The suggested framework would allow these patterns to be mapped, thereby enabling public health planners to strategically target health literacy promotion programmes to the right population segments at the right time.

Early life risk and resiliency factors and their influences on developmental outcomes and disease pathways: a rapid evidence review of systematic reviews and meta-analyses

The Developmental Origins of Health and Disease (DOHaD) framework aims to understand how environmental exposures in early life shape lifecycle health. Our understanding and the ability to prevent poor health outcomes and enrich for resiliency remain limited, in part, because exposure-outcome relationships are complex and poorly defined. We, therefore, aimed to determine the major DOHaD risk and resilience factors. A systematic approach with a 3-level screening process was used to conduct our Rapid Evidence Review following the established guidelines. Scientific databases using DOHaD-related keywords were searched to capture articles between January 1, 2009 and April 19, 2019. A final total of 56 systematic reviews/meta-analyses were obtained. Studies were categorized into domains based on primary exposures and outcomes investigated. Primary summary statistics and extracted data from the studies are presented in Graphical Overview for Evidence Reviews diagrams. There was substantial heterogeneity within and between studies. While global trends showed an increase in DOHaD publications over the last decade, the majority of data reported were from high-income countries. Articles were categorized under six exposure domains: Early Life Nutrition, Maternal/Paternal Health, Maternal/Paternal Psychological Exposure, Toxicants/Environment, Social Determinants, and Others. Studies examining social determinants of health and paternal influences were underrepresented. Only 23% of the articles explored resiliency factors. We synthesized major evidence on relationships between early life exposures and developmental and health outcomes, identifying risk and resiliency factors that influence later life health. Our findings provide insight into important trends and gaps in knowledge within many exposures and outcome domains.

"It's Never Too Early": Preconception Care and Postgenomic Models of Life

In this article, we are concerned with the expanded public health interest in the "preconception period" as a window of opportunity for intervention to improve long-term population health outcomes. While definitions of the "preconception period" remain vague, new classifications and categories of life are becoming formalized as biomedicine begins to conduct research on, and suggest intervention in, this undefined and potentially unlimited time before conception. In particular, we focus on the burgeoning epidemiological interest in epigenetics and Developmental Origins of Health and Disease (DOHaD) research as simultaneously a theoretical spyglass into postgenomic biology and a catalyst toward a public health focus on preconception care. We historicize the notion that there are long-term implications of parental behaviors before conception, illustrating how, as Han and Das have noted, "newness comes to be embedded in older forms even as it transforms them" (Han and Das, 2015, p. 2). We then consider how DOHaD frameworks justify a number of fragmented claims about preconception by making novel evidentiary assertions. Engaging with the philosophy of Georges Canguilhem, we examine the relationship between reproductive risk and revised understandings of biological permeability, and discuss some of the epistemic and political implications of emerging claims in postgenomics.