Dougal S Hargreaves

Deaths in young people aged 0–24 years in the UK compared with the EU15+ countries, 1970–2008: analysis of the WHO Mortality Database

BACKGROUND Concern is growing that mortality and health in children and young people in the UK lags behind that of similar countries. METHODS We analysed death registry data provided to the WHO Mortality Database to compare UK mortality for children and young people aged 0-24 years with that of European Union member states (before May, 2004, excluding the UK, plus Australia, Canada, and Norway [the EU15+ countries]) from 1970 to 2008 using the WHO World Mortality Database. We grouped causes of death by Global Burden of Disease classification: communicable, nutritional, or maternal causes; non-communicable disorders; and injury. UK mortality trends were compared with quartiles of mortality in EU15+ countries. We used quasi-likelihood Poisson models to explore differences between intercepts and slopes between the UK and the EU15+ countries. FINDINGS In 1970, UK total mortality was in the best EU15+ quartile (<25th centile) for children and young people aged 1-24 years, with UK infant mortality similar to the EU15+ median. Subsequent mortality reductions in the UK were smaller than were those in the EU15+ countries in all age groups. By 2008, total mortality for neonates, infants, and children aged 1-4 years in the UK was in the worst EU15+ quartile (>75th centile). In 2008, UK annual excess mortality compared with the EU15+ median was 1035 deaths for infants and 134 for children aged 1-9 years. Mortality from non-communicable diseases in the UK fell from being roughly equivalent to the EU15+ median in 1970 to the worst quartile in all age groups by 2008, with 446 annual excess deaths from non-communicable diseases in the UK (280 for young people aged 10-24 years) in 2008. UK mortality from injury remained in the best EU15+ quartile for the study period in all age groups. INTERPRETATION The UK has not matched the gains made in child, adolescent, and young adult mortality by other comparable countries in the 40 years since 1970, particularly for infant deaths and mortality from non-communicable diseases, including neuropsychiatric disorders. The UK needs to identify and address amenable social determinants and health system factors that lead to poor health outcomes for infants and for children and young people with chronic disorders. FUNDING None.

Inequality trends in health and future health risk among English children and young people, 1999–2009

Objective To investigate trends in health inequality among children and young people between 1999 and 2009, using outcomes consistent with the current NHS reforms. Design/data Secondary analysis of participants aged 0–24 in the Health Surveys for England (HSE) undertaken in 1999, 2004, 2006 and 2009. Main outcome measures Changes in the absolute and relative risks of four health outcomes by deprivation tertiles, based on occupation of the head of household ▸ self/parent-reported general health, ▸ presence of a long-standing illness (LSI), ▸ obesity ▸ smoking. Results No indicator showed a reduction in relative or absolute inequality between 1999 and 2009. For children (0–12 years), the relative risk comparing the most and least deprived tertiles increased significantly for poor general health (1999:1.6 (95% CI 1.2 to 2.2); 2009:3.9 (2.4 to 6.2), while the absolute difference in LSI prevalence(%) increased from 1.3 (−2.9 to 5.5) to 7.4 (3.6 to 11.4). Among young people (13–24 years), the absolute difference in LSI prevalence increased from −5.9 (−10.9 to −1.1) to 3.1 (−4.1 to 10.7). Absolute inequality in having tried smoking among children aged 8–15(%) increased significantly in the first half of the decade before decreasing in the second half (1999:3.3 (−1.1 to 7.7); 2004:14.1 (9.6 to 18.8); 2009:4.1 (0.1 to 8.8)). However, the increase in absolute inequality for smoking prevalence among young adults (16–24 years) was maintained throughout the decade (1999:−7.0 (−15.6 to 1.3); 2004:11.6 (3.7 to 20.0); 2009:8.2 (−0.3 to 16.9)). Conclusions The national programme between 1999 and 2009 was not successful in reducing inequality in four key indicators of health status and future health risk among children and young people. Some inequality measures for general health, LSI prevalence and smoking increased over this time.

Unmet Health Care Need in US Adolescents and Adult Health Outcomes.

BACKGROUND: Adolescence is a formative period when health care services have a unique opportunity to influence later health outcomes. Unmet health care need in adolescence is known to be associated with poor contemporaneous health outcomes; it is unknown whether it predicts poor adult health outcomes. METHODS: We used nationally representative data from 14 800 subjects who participated in Wave I (mean age: 15.9 years [1994/1995]) and Wave IV (mean age: 29.6 years [2008]) of the National Longitudinal Study of Adolescent to Adult Health. Logistic regression models were used to estimate the association between unmet health care need in adolescence and 5 self-reported measures of adult health (fair/poor general health, functional impairment, time off work/school, depressive symptoms, and suicidal ideation). Models were adjusted for baseline health, insurance category, age, gender, race/ethnicity, household income, and parental education. RESULTS: Unmet health care need was reported by 19.2% of adolescents and predicted worse adult health: fair/poor general health (adjusted odds ratio [aOR]: 1.27 [95% confidence interval (CI): 1.00–1.60]); functional impairment (aOR: 1.52 [95% CI: 1.23–1.87]); depressive symptoms (aOR: 1.36 [95% CI: 1.13–1.64]); and suicidal ideation (aOR: 1.30 [95% CI: 1.03–1.68]). There was no significant association between unmet health care need and time off work/school (aOR: 1.13 [95% CI: 0.93–1.36]). Cost barriers accounted for only 14.8% of unmet health care need. The reason for unmet need was not significantly related to the likelihood of poor adult health outcomes. CONCLUSIONS: Reported unmet health care need in adolescence is common and is an independent predictor of poor adult health. Strategies to reduce unmet adolescent need should address health engagement and care quality, as well as cost barriers to accessing services.

The voices of children and young people in health: where are we now?

‘Make decisions about us, with us. Let us have our say!’  Royal College of Paediatrics & Child Health Youth Advisory Panel member1 Universal childrens day on 20 November 2014 marked the 25th anniversary of the UN Convention on the Rights of the Child (UNCRC,1989)2 and the 55th anniversary of the Declaration of the Rights of the Child (1959).3 Twenty-five years after the UNCRC, this article explores the rights of children and young people (CYP) to participate in decisions about their healthcare, and the benefits of doing so; we then examine where we are now with respect to the voices of CYP in health. This article addresses this final question through three aspects: first, by celebrating the progress made over the last quarter of a century—particularly with respect to policy development—both in the UK and internationally; second, by identifying ongoing areas of concern, with suggestions as to where to focus our efforts next; and finally, by calling for a change in culture. This change of culture is suggested through four positive concrete steps: a greater dissemination of guidance and examples of good practice, greater evaluation of the participatory process, appropriate training and procedures in place to support CYP participation and finally encouraging increased involvement of CYP in improving their own health. Through these steps, we aim towards a culture where CYP are valued, heard, understood and, ultimately, their rights are respected. With the UNCRC having been ratified by most UN member countries (the UK in 1991), such landmark agreements focus attention on the fundamental and inalienable rights applicable to every child and young person worldwide. An important element of these rights is the right to participate in decisions about their own care, including their healthcare. Support for the participatory role of CYP includes the right to express their …

School-Level Variation in Health Outcomes in Adolescence: Analysis of Three Longitudinal Studies in England

School factors are associated with many health outcomes in adolescence. However, previous studies report inconsistent findings regarding the degree of school-level variation for health outcomes, particularly for risk behaviours. This study uses data from three large longitudinal studies in England to investigate school-level variation in a range of health indicators. Participants were drawn from the Longitudinal Study of Young People in England, the Me and My School Study and the Research with East London Adolescent Community Health Survey. Outcome variables included risk behaviours (smoking, alcohol/cannabis use, sexual behaviour), behavioural difficulties and victimisation, obesity and physical activity, mental and emotional health, and educational attainment. Multi-level models were used to calculate the proportion of variance in outcomes explained at school level, expressed as intraclass correlations (ICCs) adjusted for gender, ethnicity and socio-economic status of the participants. ICCs for health outcomes ranged from nearly nil to .28 and were almost uniformly lower than for attainment (.17–.23). Most adjusted ICCs were smaller than unadjusted values, suggesting that school-level variation partly reflects differences in pupil demographics. School-level variation was highest for risk behaviours. ICCs were largely comparable across datasets, as well as across years within datasets, suggesting that school-level variation in health remains fairly constant across adolescence. School-level variation in health outcomes remains significant after adjustment for individual demographic differences between schools, confirming likely effects for school environment. Variance is highest for risk behaviours, supporting the utility of school environment interventions for these outcomes.

Relative importance of individual and social factors in improving adolescent health

Aims: In 2010, the English Department of Health launched a radical new public health strategy, which sees individual factors, such as self-esteem, as the key to improving all aspects of young people’s health. This article compares the strength of association between key adolescent health outcomes and a range of individual and social factors Methods: All participants aged 12–15 in the nationally representative 2008 Healthy Foundations survey were included. Six individual factors related to self-esteem, confidence and personal responsibility, and seven social factors related to family, peers, school and local area were investigated. Single-factor and multivariable logistic regression models were used to calculate the association between these factors and seven health outcomes (self-reported general health, physical activity, healthy eating, weight, smoking, alcohol intake, illicit drug use). Odds ratios were adjusted for gender, age and deprivation. Results: Individual factors such as self-esteem were associated with general health, physical activity and healthy eating. However, the influence of family, peers, school and local community appear to be equally important for these outcomes and more important for smoking, drug use and healthy weight. Conclusion: Self-esteem interventions alone are unlikely to be successful in improving adolescent health, particularly in tackling obesity and reducing substance misuse.

The impact of out-of-hospital models of care on paediatric emergency department presentations

Objective To estimate the potential impact of enhanced primary care and new out-of-hospital models (OOHMs) on emergency department (ED) presentations by children and young people (CYP). Design Observational study. Patients & setting Data collected prospectively on 3020 CYP 0–17.9 years from 6 London EDs during 14 days by 25 supernumerary clinicians. CYP with transient acute illness, exacerbation of long-term condition (LTC), complex LTC/disability and injury/trauma were considered manageable within OOHM. OOHMs assessed included nurse-led services, multispecialty community provider (MCP), primary and acute care system (PACS) plus current and enhanced primary care. Measures Diagnosis, severity; record of investigations, management and outcome that occurred; objective assessment of clinical need and potential alternative management options/destinations. Results Of the patients 95.6% had diagnoses appropriate for OOHM. Most presentations required assessment by a clinician with skills in assessing illness (39.6%) or injuries (30.9%). One thousand two hundred and ninety-one (42.75%) required no investigations and 1007 (33.3%) were provided only with reassurance. Of the presentations 42.2% were judged to have been totally avoidable if the family had had better health education. Of the patients 26.1% were judged appropriate for current primary care (community pharmacy or general practice) with 31.5% appropriate for the combination of enhanced general practice and community pharmacy. Proportions suitable for new models were 14.1% for the nurse-led acute illness team, MCP 25.7%, GP federation CYP service 44.6%, comprehensive walk-in centre for CYP 64.3% and 75.5% for a PACS. Conclusions High proportions of ED presentations by CYP could potentially be managed in new OOHMs or by enhancement of existing primary care.

The health benefits of secondary education in adolescents and young adults: An international analysis in 186 low-, middle- and high-income countries from 1990 to 2013

Background The health benefits of secondary education have been little studied. We undertook country-level longitudinal analyses of the impact of lengthening secondary education on health outcomes amongst 15-24 year olds. Methods Exposures: average length of secondary and primary education from 1980 to 2013. Data/Outcomes: Country level adolescent fertility rate (AFR), HIV prevalence and mortality rate from 1989/90 to 2013 across 186 low-, middle- and high-income countries. Analysis: Longitudinal mixed effects models, entering secondary and primary education together, adjusted for time varying GDP and country income status. Longitudinal structural marginal models using inverse probability weighting (IPW) to take account of time varying confounding by primary education and GDP. Counterfactual scenarios of no change in secondary education since 1980/1990 were estimated from model coefficients for each outcome. Findings Each additional year of secondary education decreased AFR by 8.4% in mixed effects models and 14.6% in IPW models independent of primary education and GDP. Counterfactual analyses showed the proportion of the reduction in adolescent fertility rate over the study period independently attributable to secondary education was 28% in low income countries. Each additional year of secondary education reduced mortality by 16.9% for 15-19 year and 14.8% for 20-24 year old young women and 11.4% for 15-19 year and 8.8% for 20-24 year old young men. Counterfactual scenarios suggested 12% and 23% of the mortality reduction for 15-19 and 20-24 year old young men was attributable to secondary education in low income countries. Each additional year of secondary education was associated with a 24.5% and 43.1% reduction in HIV prevalence amongst young men and women. Interpretation The health benefits associated with secondary education were greater than those of primary education and were greatest amongst young women and those from low income countries. Secondary education has the potential to be a social vaccine across many outcomes in low and middle income countries.

Integrated care for childhood epilepsy: ongoing challenges and lessons for other long-term conditions

Epilepsy care has been identified as a major global issue—and there are many recognised concerns in the UK for children and young people with the condition. A proposed new model could help to increase multisector integration, facilitate better outcomes and offer lessons for improving care of other long-term conditions.

Little evidence that increased choice and competition in the English National Health Service will benefit children and young people

Government plans to increase choice and competition in the National Health Service (NHS) will be implemented from April 2012 and will affect services for all age groups. The Royal College of Paediatrics and Child Health and the NHS Confederation recently expressed concerns that this approach might impede integration and coordination of care for younger patients. They recommend that ‘the Any Qualified Provider policy should only be used for child healthcare services where there are clear benefits to patients’.1 In support of the reforms, the …