The impact of school exclusion in childhood on health and well-being outcomes in adulthood: Estimating causal effects using inverse probability of treatment weighting

BACKGROUND

Previous evidence has suggested a strong association between school exclusion and health outcomes. However, as health risks are themselves related to the risk of experiencing a school exclusion, it has been challenging to determine the extent to which school exclusion impacts later health outcomes, as opposed to reflecting a marker for pre-existing risks.

AIM

The aim of the current study was to address this challenge in estimating the medium-to-long-term impact of school exclusion of health and well-being outcomes.

METHODS

To this end, we used an inverse propensity weighting approach in the Next Steps data set (N = 6534, from wave 1, 2014, to wave 8, 2015).

RESULTS

We found that after weighting for propensity of treatment scores estimated based on a wide range of factors, including previous health indicators, there was a significant effect of school exclusion on a wide range of health and well-being outcomes.

DISCUSSION

These results provide some of the most robust evidence to date that school exclusion harms long-term health outcomes.

CONCLUSION

The findings suggest that policies should aim to reduce exclusion and ensure access to preventative health support for those who experience a school exclusion.

146 Epilepsy, deprivation and mortality in Wales 2005–2017

Background

Public Health England have recently reported that deaths associated with epilepsy are increasing and are associated with increased deprivation. We investigated comparable Welsh mortality trends and associations between epilepsy mortality and deprivation.

Method

We used routinely-collected health data within the Secure Anonymised Information Linkage (SAIL) Databank. We recorded deaths associated with epilepsy (DAE), epilepsy recorded on death certificates, and deaths in people with epilepsy (DPWE), people with diagnoses of epilepsy and epilepsy prescriptions before death. We compared death rates in different deprivation deciles adjusting for epilepsy prevalence.

Results

During 2005–2017 (41million patient-years) there were 2116 DAE and 7821 DPWE. DAE and DPWE increased from 4.3/100,000/yr and 17.2/100,000/yr in 2005–2007 to 5.7/100,000/yr and 20.9/100,000/yr in 2015–2017. The age-standardised mortality rates (ASMR) in 2006–2008 for DAE and DPWE were 5.3/100,000/yr and 20/100,000/yr respectively, in 2015–2017 they were 5.8/100,000/yr and 20/100,000/yr. DAE were not significantly associated with deprivation when adjusted for epilepsy prevalence.

Conclusion

When adjusting for age, deaths associated wtih epilepsy and deaths in people with epilepsy did not increase significantly in Wales between 2005–2007 and 2015–2017. The association between dep- rivation and deaths associated with epilepsy appears to be explained by higher epilepsy prevalence in areas of higher deprivation.

w.o.pickrell@swansea.ac.uk

Long-term labour market and economic consequences of school exclusions in England: Evidence from two counterfactual approaches

Background

Previous research suggests that school exclusion during childhood is a precursor to social exclusion in adulthood. Past literature on the consequences of school exclusion is, however, scarce and mainly focused on short‐term outcomes such as educational attainment, delinquency, and mental health in early adolescence. Moreover, this evidence is based primarily on descriptive and correlational analysis, whereas robust causal evidence is required to best inform policy.

Aims

We aimed to estimate the mid‐to‐long‐term impact of school exclusion on labour market and economic outcomes.

Sample

The sample included 6,632 young people who at the age of 25/26 in the year 2015 participated in the Next Steps survey of whom 86 were expelled from school and 711 were suspended between the ages of 13/14 and 16/17.

Method

Using high quality existing longitudinal data, we utilized four approaches to evaluate the impact of school exclusion: logistic regression‐adjustment models, propensity score matching, school fixed‐effects analysis, and inverse propensity weighting. The latter two counterfactual approaches were used to estimate causal effects.

Results

We found that school exclusion increased the risk of becoming NEET at the age of 19/20, and then remaining economically inactive at the age of 25/26, as well as experiencing higher unemployment risk and earning lower wages also at the age of 25/26.

Conclusion

School exclusion has pervasive negative effects into adulthood. Policy interventions should focus on both prevention and mitigating its negative effects. Interventions aimed at re‐integrating excluded individuals into education or vocational training could be key in reducing the risk of poor socio‐economic outcomes and social exclusion.

Surprising impact of stromal TIL's on immunotherapy efficacy in a real-world lung cancer study

INTRODUCTION

Immune checkpoint inhibitors (ICI), such as anti-PD-1 agents, have become part of the standard of care treatment of advanced non-small cell lung cancer (NSCLC). Predictive biomarkers are needed to identify patients that benefit from anti-PD-1 treatments. Tumor infiltrating lymphocytes (TILs) and PD-L1 are major players in the ICI mechanism of action. In this study, we assess the impact of real-world clinicopathological variables, including TILs and PD-L1, on anti-PD-1 efficacy.

METHODS

We performed a monocenter retrospective study in advanced NSCLC treated with nivolumab or pembrolizumab between January 2015 and February 2019. The impact of baseline clinical and pathological variables was assessed by univariate and multivariate models. TILs, defined as CD8+T-cells, and PD-L1 were scored in tumor and stroma, and correlated with progression free survival (PFS) and overall survival (OS).

RESULTS

We included 366 patients of whom 141 were assessed for tumor and stromal TILs. The median follow-up time was 487 days. In the whole cohort, PFS was associated with high tumor PD-L1, high albumin and good performance. OS was associated with low LDH, high albumin, good performance and 'first-line treatment'. In the TILs subcohort, stromal TILs had the strongest impact on PFS and OS. Stromal TILs were a stronger marker for PFS and OS than tumoral TILs, tumoral PD-L1 or stromal PD-L1. Remaining factors for PFS and OS were albumin and albumin with LDH, respectively.

CONCLUSIONS

This real-world study on clinicopathological features shows that stromal CD8 + TILs were the strongest predictor for PFS and OS in patients with advanced NSCLC on anti-PD-1 therapy. Other predictors for PFS and OS included albumin and albumin together with LDH, respectively. This study highlights the pivotal role of the stromal compartment in the mechanisms of action of ICI, and the need for further studies aiming to overcome this stromal firewall.

Exploring barriers and solutions in advancing cross-centre population data science

INTRODUCTION

It is widely acknowledged that population health and administrative data, especially when linked at the individual level, hold great value for research. Cross-centre working between data centres providing access to such data has the potential to further increase this value by effectively expanding the data available for research. However, there is limited published information on how to address the challenges and achieve success. The aim of this paper is to explore perceived barriers and solutions to inform developments in cross-centre working across data centres.

METHODS

We carried out a narrative literature review on data sharing and cross centre working. We used a mixed methods approach to assess the opinions of members of the public on cross-centre data sharing, and the views and experiences of among data centre staff connected with the UK Farr Institute for Health Informatics Research.

RESULTS

The literature review uncovered a myriad of practical and cultural issues. Our engagement with a public group suggested that cross-centre working involving anonymised data being moved between established centres is considered acceptable. The main themes emerging from discussions with data centre staff were dedicated resourcing, practical issues, information governance and culture.

CONCLUSION

In seeking to advance cross-centre working between data centres, we conclude that there is a need for dedicated resourcing, indicators to recognise data reuse, collaboration to solve common issues, and balancing necessary barrier removal with incentivisation. This will require on-going commitment, engagement and an academic culture change.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Vitrification as an Alternative Approach for Sperm Cryopreservation in Marine Fishes

The Southern Flounder Paralichthys lethostigma is a high-value species and a promising aquaculture candidate. Because sperm volume can be limited in this species (<500 μL), new sperm cryopreservation methods need to be evaluated. Vitrification is an alternative to conventional slow-rate freezing, whereby small volumes are cryopreserved at high cooling rates (>1,000°C/min). The goal of this work was to develop a standardized approach for vitrification of Southern Flounder sperm. The specific objectives were to (1) evaluate thawing methods and vitrification solutions, (2) evaluate the postthaw membrane integrity of sperm vitrified in different cryoprotectant solutions, (3) examine the relationship between membrane integrity and motility, and (4) evaluate the ability of vitrified sperm to fertilize eggs. From the vitrification solutions tested, the highest postthaw motility (28 ± 9% [mean ± SD]) and membrane integrity (11 ± 4%) was observed for 20% ethylene glycol plus 20% glycerol. There was no significant difference in postthaw motility of sperm thawed at 21°C or at 37°C. Fertilization from vitrified sperm in one trial yielded the same fertilization rate (50 ± 20%) as the fresh sperm control, while the sperm from the other two males yielded 3%. This is the first report of fertilization by vitrified sperm in a marine fish. Vitrification can be simple, fast, inexpensive, performed in the field, and, at least for small fishes, offers an alternative to conventional cryopreservation. Because of the minute volumes needed for ultrarapid cooling, vitrification is not presently suited as a production method for large fishes. Vitrification can be used to reconstitute lines from valuable culture species and biomedical models, conserve mutants for development of novel lines for ornamental aquaculture, and transport frozen sperm from the field to the repository to expand genetic resources.

Coupling aquaculture with forest plantations for food, energy, and water resiliency

Freshwater aquaculture and forest bioenergy markets are expanding globally in areas concurrently experiencing human population growth, urbanization and water shortages. Coupling these agroecosystems can improve food, energy, and water resiliency by enhancing ecosystem services through fertilization, water-reuse, carbon storage, and bioenergy via biomass production. This study evaluated how a model aquaculture-managed forest plantation could (1) provision fish and woody biomass; (2) regulate carbon, groundwater infiltration, and groundwater quality; and (3) support nutrient cycling over a two-year period. A 0.5-hectare hardwood bioenergy plantation was established with 12 Populus spp. genotypes adjacent to a 0.6-hectare freshwater aquaculture operation (hybrid striped bass, Morone chrysops×M. saxatilis); pond waters were land-applied on the plantation for two years. The aquaculture operation produced ~3.5Mg of fish and trees yielded 5.9Mgha(-1)yr(-1) of oven-dry biomass, sequestered 2.9Mg carbon (C) ha(-1)yr(-1) and stored 0.028Mg nitrogen (N) ha(-1)yr(-1). Biomass productivity, carbon storage, and nitrogen storage differed significantly among the evaluated Populus genotypes. Land application of pond water increased groundwater infiltration by 60% relative to the previous year. The integrated system regulated chlorophyll a, total organic carbon, and nitrogen in groundwater at concentrations below regulatory limits. This study demonstrated that coupled agroecosystems could deliver productive yields of food and bioenergy as well as support water re-use while meeting water quality regulations. More research is needed to evaluated long-term sustainability and economic viability of this coupled system and other land management practices that seek to improve food, energy, and water resiliency.

The ‘Social’ in Post-Vygotskian Theory

In this article some limitations of the increasingly popular theories of the Russian semiotician L.S. Vygotsky will be identified. Emphasis will be placed on the lack of an account of social positioning within discourse as well as the social, cultural and historical production of discourse. At the heart of these concerns there lies an underdeveloped perspective on the social function of language, particularly when it is used to influence interpersonal relations. The theories of cultural transmission developed by Basil Bernstein in the later stages of his career will be discussed in terms of the potential for refining the Vygotskian thesis.

The Concept of Drama in Vygotsky’s Theory: Application in Research

The article focuses on some aspects of L.S. Vygotsky’s early works, which are interpreted as the under- lying basis of the cultural-historical theory and might be applied while conducting research in the framework of this scientific school. The concepts of “drama”, “pereghivanie” and “reflective communication” as well as their role in applying experimental-genetic method in research are analysed. Results of a research project “Drama and exclusion”, conducted in the UK in 2014—2015 on the basis of two arts-based organisations working with young people with various kinds of social, emotional and behavioural difficulties, are discussed. A case-study with a group of children at risk of school exclusion is given as an example of applying a “dramatic event” as a cultural tool for reorganising the social situation of development.

A cluster randomised controlled trial comparing the effectiveness and cost-effectiveness of a school-based cognitive–behavioural therapy programme (FRIENDS) in the reduction of anxiety and improvement in mood in children aged 9/10 years

Background

Anxiety in children is common, impairs everyday functioning and increases the risk of severe mental health disorders in adulthood, yet few children with anxiety are identified and referred for treatment.

Objective

To investigate the clinical effectiveness and cost-effectiveness of a universal school-based preventative programme (FRIENDS) in reducing symptoms of anxiety and low mood.

Design

Cluster randomised controlled trial. Schools (n = 41) were randomly assigned after recruitment on a 1 : 1 : 1 basis to health-led FRIENDS, school-led FRIENDS and usual school provision.

Setting

Primary schools in three local education authorities in the south-west of England.

Participants

Children (n = 1362) aged 9–10 years attending school and participating in personal, social and health education (PSHE).

Interventions

The FRIENDS programme is a cognitive–behavioural therapy programme that develops skills to counter the cognitive, emotional and behavioural aspects of anxiety. The FRIENDS programme was led by either a trained member of the school or a health leader external to the school and was delivered over 9 consecutive weeks. The comparison group received usual school PSHE lessons. Interventions were delivered in the academic year September 2011–July 2012.

Main outcome measures

Clinical effectiveness assessed by child report of symptoms of anxiety (Revised Child Anxiety and Depression Scale, RCADS); cost-effectiveness based on RCADS and quality-adjusted life-years (Child Health Utility 9 Dimensions, CHU-9D) between baseline and 6 months; process evaluation, evaluation of reach and attrition and qualitative feedback from children, school staff and parents.

Results

At 12 months there was a difference in the adjusted mean RCADS scores for health-led FRIENDS compared with school-led FRIENDS [–3.91, 95% confidence interval (CI) –6.48 to –1.35] and for health-led FRIENDS compared with usual school provision (–2.66, 95% CI –5.22 to –0.09). At 24 months we were able to assess only 43.6% of our cohort. There were few differences in baseline characteristics between completers and non-completers. Child-reported anxiety in all three groups had reduced by 24 months and there were no longer any group effects. There were no between-group effects for any parent- or child-completed secondary outcomes at 12 or 24 months. The cost of the FRIENDS programme was £52–56 per child. We found no evidence that the FRIENDS programme was cost-effective over a 6-month period; however, our subgroup for the economic analysis differed significantly from our main trial cohort.

Conclusions

Although greater reductions in anxiety were noted at 12 months when the FRIENDS programme was delivered by health leaders, these additional benefits were not maintained at 24 months. Children’s anxiety levels improved irrespective of the intervention that they received. Our economic evaluation and 24-month assessment had significant shortcomings. However, the universal delivery of specific anxiety prevention programmes will result in additional costs that may be beyond the finances available to most schools. Future work should identify the active ingredients and potential moderators of universal anxiety programmes to determine whether programme length can be reduced, short-term effectiveness maintained and cost-effectiveness improved. At present, our results find limited evidence to support the universal provision of specific anxiety prevention programmes in UK primary schools.

Trial registration

Current Controlled Trials ISRCTN23563048.

Funding

The National Institute for Health Research Public Health Research programme.

Classroom-based cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES)

BACKGROUND

Anxiety in children is common, impairs everyday functioning, and increases the risk of severe mental health disorders in adulthood. We investigated the effect of a classroom-based cognitive behaviour therapy prevention programme (FRIENDS) on anxiety symptoms in children.

METHODS

Preventing Anxiety in Children though Education in Schools (PACES) is a three-group parallel cluster randomised controlled trial. Interventions were given between September, 2011, and July, 2012, with schools as the unit of allocation and individual participants as the unit of analysis. We enrolled state-funded junior schools in southwest England. We sent information to all eligible schools (state-funded junior schools in southwest England) inviting them to enrol in the study. School year groups were assigned by computer-generated randomisation (1:1:1) to receive either school-led FRIENDS (led by teacher or school staff member), health-led FRIENDS (led by two trained health facilitators), or usual school provision. Children were not masked to treatment allocation. The allocated programme was given to all students (aged 9-10 years) in the school year (ie, universal delivery) as part of the school curriculum as nine, 60 min weekly sessions. Outcomes were collected by self-completed questionnaire administered by researchers masked to allocation. Primary outcome was symptoms of anxiety and low mood at 12 months assessed by the Revised Child Anxiety and Depression Scale (RCADS 30). Analyses were intention to treat and accounted for the clustered nature of the design. The study is registered, number ISRCTN23563048.

FINDINGS

45 schools were enrolled: 14 (n=497 children) were randomly assigned to school-led FRIENDS, 14 (n=509) to health-led FRIENDS, and 12 (n=442) to usual school provision. 1257 (92%) children completed 12 month assessments (449 in health-led FRIENDS, 436 in school-led FRIENDS, and 372 in usual school provision). We recorded a difference at 12 months in adjusted mean child-reported RCADS scores for health-led versus school-led FRIENDS (19·49 [SD 14·81] vs 22·86 [15·24]; adjusted difference -3·91, 95% CI -6·48 to -1·35; p=0·0004) and health-led FRIENDS versus usual school provision (19·49 [14·81] vs 22·48 [15·74]; -2·66, -5·22 to -0·09; p=0·043). We noted no differences in parent or teacher ratings. Training teachers to deliver mental health programmes was not as effective as delivery by health professionals.

INTERPRETATION

Universally delivered anxiety prevention programmes can be effective when used in schools. However, programme effectiveness varies depending on who delivers them.

FUNDING

National Institute for Health Research Public Health Research Programme.

The prevention of anxiety in children through school-based interventions: study protocol for a 24-month follow-up of the PACES project

BACKGROUND

Anxiety in children is common and incapacitating and increases the risk of mental health disorders in adulthood. Although effective interventions are available, few children are identified and referred for specialist treatment. Alternative approaches in which prevention programmes are delivered in school appear promising. However, comparatively little is known about the best intervention leader (health care-led vs. school-led), long-term effects or the primary preventive value of such programmes.

METHODS/DESIGN

Preventing Anxiety in Children through Education in Schools, or PACES, is a pragmatic cluster randomised controlled trial evaluating the effectiveness of a cognitive-behavioural therapy prevention programme (FRIENDS) on symptoms of anxiety and low mood in 9- to 10-year-old children. Forty-one schools were randomly assigned to one of three conditions: school-led FRIENDS, health care-led FRIENDS or treatment as usual. Assessments were undertaken at baseline, 6 months and 12 months, with the primary outcome measure being the Revised Child Anxiety and Depression Scale score at 12 months. Secondary outcome measures are changes in self-esteem, worries, bullying and life satisfaction.

DISCUSSION

This protocol summarises the procedure for the 24-month follow-up of this cohort. The study will determine the medium-term effectiveness of an anxiety prevention programme delivered in schools.

TRIAL REGISTRATION

ISRCTN23563048.