Staffan Janson

Burden and consequences of child maltreatment in high-income countries.

Child maltreatment remains a major public-health and social-welfare problem in high-income countries. Every year, about 4-16% of children are physically abused and one in ten is neglected or psychologically abused. During childhood, between 5% and 10% of girls and up to 5% of boys are exposed to penetrative sexual abuse, and up to three times this number are exposed to any type of sexual abuse. However, official rates for substantiated child maltreatment indicate less than a tenth of this burden. Exposure to multiple types and repeated episodes of maltreatment is associated with increased risks of severe maltreatment and psychological consequences. Child maltreatment substantially contributes to child mortality and morbidity and has longlasting effects on mental health, drug and alcohol misuse (especially in girls), risky sexual behaviour, obesity, and criminal behaviour, which persist into adulthood. Neglect is at least as damaging as physical or sexual abuse in the long term but has received the least scientific and public attention. The high burden and serious and long-term consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood.

Self-rated health, chronic diseases, and symptoms among middle-aged and elderly men and women

The objective was to study the association between chronic diseases, symptoms, and poor self-rated health among men and women and in different age groups, and to assess the contribution of chronic diseases and symptoms to the burden of poor self-rated health in the general population. Self-rated health and self-reported diseases and symptoms were investigated in a population sample of 6,061 men and women aged 35-79 years in Värmland County in Sweden. Odds ratios (OR) and population attributable risks (PAR) were calculated to quantify the contribution of chronic diseases and symptoms to poor self-rated health. Depression, neurological disease, rheumatoid arthritis, and tiredness/weakness had the largest contributions to poor self-rated health in individuals. Among the elderly (65-79 years), neurological disease and cancer had the largest contribution to self-rated health in men, and renal disease, rheumatoid arthritis, and cancer in women. Among the middle-aged (35-64 years), depression and tiredness/weakness were also important, especially in women. From a population perspective, tiredness/weakness explained the largest part of poor self-rated health due to its high prevalence in the population. Depression and musculoskeletal pains were also more important than other chronic diseases and symptoms at the population level. Even though many chronic diseases (such as neurological disease, rheumatoid arthritis, and cancer) are strongly associated with poor self-rated health in the individual, common symptoms (such as tiredness/weakness and musculoskeletal pains) as well as depression contribute more to the total burden of poor self-rated health in the population. More preventive measures should therefore be directed against these conditions, especially when they are not consequences of other diseases.

Child maltreatment: variation in trends and policies in six developed countries

We explored trends in six developed countries in three types of indicators of child maltreatment for children younger than 11 years, since the inception of modern child protection systems in the 1970s. Despite several policy initiatives for child protection, we recorded no consistent evidence for a decrease in all types of indicators of child maltreatment. We noted falling rates of violent death in a few age and country groups, but these decreases coincided with reductions in admissions to hospital for maltreatment-related injury only in Sweden and Manitoba (Canada). One or more child protection agency indicators increased in five of six countries, particularly in infants, possibly as a result of early intervention policies. Comparisons of mean rates between countries showed five-fold to ten-fold differences in rates of agency indicators, but less than two-fold variation in violent deaths or maltreatment-related injury, apart from high rates of violent child death in the USA. These analyses draw attention to the need for robust research to establish whether the high and rising rates of agency contacts and out-of-home care in some settings are effectively reducing child maltreatment.

Health services for children in western Europe

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

Physical activity and quality of life in subjects with chronic disease: Chronic obstructive pulmonary disease compared with rheumatoid arthritis and diabetes mellitus

Objective. Chronic diseases interfere with the life situation of the affected person in different ways. The aim was to compare the burden of disease in three chronic diseases – chronic obstructive pulmonary disease (COPD), rheumatoid arthritis (RA), diabetes mellitus (DM) – and in healthy subjects, with a particular interest in physical activity, quality of life, and psychological health. Design. Cross-sectional, observational study. Setting and subjects. Postal survey questionnaire to a stratified, random population of 68 460 subjects aged 18–84 years in Sweden. The subjects included were 40–84 years old (n = 43 589) and data were analysed for COPD (n = 526), RA (n = 1120), DM (n = 2149) and healthy subjects (n = 6960). Result: Some 84% of subjects with COPD, 74% (RA), 72% (DM), and 60% in healthy subjects (p < 0.001, COPD versus RA, DM, and healthy subjects) had a physical activity level considered too low to maintain good health according to guidelines. Quality of life (EuroQol five-dimension questionnaire, EQ-5D) was lower in COPD and RA than in DM. Anxiety/depression was more common in subjects with COPD (53%) than in those with RA (48%) and DM (35%) (p < 0.001, COPD versus RA and DM), whereas mobility problems were more common in RA (55%) than COPD (48%) and DM (36%) (p < 0.001, RA versus COPD and DM). All differences between groups remained significant after adjusting for age, sex, and socioeconomic background factors. Conclusion. Subjects with chronic diseases had a low level of physical activity, most evident in subjects with COPD. COPD and RA had a higher negative impact on quality of life than DM. Our results indicate that increased attention regarding physical inactivity in subjects with chronic diseases is needed to minimize the burden of disease.

Prenatal Phthalate Exposures and Anogenital Distance in Swedish Boys

Background: Phthalates are used as plasticizers in soft polyvinyl chloride (PVC) and in a large number of consumer products. Because of reported health risks, diisononyl phthalate (DiNP) has been introduced as a replacement for di(2-ethylhexyl) phthalate (DEHP) in soft PVC. This raises concerns because animal data suggest that DiNP may have antiandrogenic properties similar to those of DEHP. The anogenital distance (AGD)—the distance from the anus to the genitals—has been used to assess reproductive toxicity. Objective: The objective of this study was to examine the associations between prenatal phthalate exposure and AGD in Swedish infants. Methods: AGD was measured in 196 boys at 21 months of age, and first-trimester urine was analyzed for 10 phthalate metabolites of DEP (diethyl phthalate), DBP (dibutyl phthalate), DEHP, BBzP (benzylbutyl phthalate), as well as DiNP and creatinine. Data on covariates were collected by questionnaires. Results: The most significant associations were found between the shorter of two AGD measures (anoscrotal distance; AGDas) and DiNP metabolites and strongest for oh-MMeOP [mono-(4-methyl-7-hydroxyloctyl) phthalate] and oxo-MMeOP [mono-(2-ethyl-5-oxohexyl) phthalate]. However, the AGDas reduction was small (4%) in relation to more than an interquartile range increase in DiNP exposure. Conclusions: These findings call into question the safety of substituting DiNP for DEHP in soft PVC, particularly because a shorter male AGD has been shown to relate to male genital birth defects in children and impaired reproductive function in adult males and the fact that human levels of DiNP are increasing globally. Citation: Bornehag CG, Carlstedt F, Jönsson BA, Lindh CH, Jensen TK, Bodin A, Jonsson C, Janson S, Swan SH. 2015. Prenatal phthalate exposures and anogenital distance in Swedish boys. Environ Health Perspect 123:101–107; http://dx.doi.org/10.1289/ehp.1408163

Improving child health services in the UK: insights from Europe and their implications for the NHS reforms

The coalition government’s Health and Social Care Bill is unlikely to deliver the improvements in children’s health services that are urgently needed. Useful lessons can be learnt from how other European countries deliver healthcare for children, say Ingrid Wolfe and colleagues

PVC--as flooring material--and its association with incident asthma in a Swedish child cohort study.

UNLABELLED The Dampness in Buildings and Health study (DBH) started in the year 2000 in Värmland, Sweden, with a baseline questionnaire sent to all children (n = 14,077) aged 1-6. Five years later, a follow-up questionnaire was sent to the children who were 1-3 years at baseline. A total of 4779 children participated in both the baseline and the follow-up studies and constitute the study population in this cohort study. The aim of this study was to examine the association between exposure to PVC-flooring in the childs and parents bedroom in homes of children aged 1-3 and the incidence of asthma, rhinitis, and eczema during the following 5-year period. Adjusted analyses showed that the incidence of asthma among children was associated with PVC-flooring in the childs bedroom (AOR 1.52; 95% CI 0.99-2.35) and in the parents bedroom (1.46; 0.96-2.23). The found risks were on borderline of significance and should therefore be interpreted with caution. There was further a positive relationship between the number of rooms with PVC-flooring and the cumulative incidence of asthma. PVC-flooring was found to be a stronger risk factor for incident asthma in multifamily homes when compared with single-family houses and in smoking families compared with non-smoking families and in women. PRACTICAL IMPLICATIONS These longitudinal data from the DBH study found an association between the presence of PVC-flooring in the home and incident asthma in children. However, earlier results from the DBH study have shown that PVC-flooring is one important source for phthalates in indoor dust, and exposure to such phthalates was found to be associated with asthma and allergy among children. This emphasizes the need for prospective studies that focus on the importance of prenatal and neonatal exposure to phthalates in the development of asthma and allergy in children.

Rock climbing injury rates and associated risk factors in a general climbing population

The objective was to examine injury rates and associated risk factors in a representative sample of climbers. A random sample (n=606) of the Swedish Climbing Association members was sent a postal survey, with an effective response rate of 63%. Self‐reported data regarding climbing history, safety practices and retrospective accounts of injury events (recall period 1.5 years) were obtained. Descriptive statistical methods were used to calculate injury incidences, and a two‐step method including zero‐inflated Poissons regression analysis of re‐injuries was used to determine the combination of risk factors that best explained individual injury rates. Overall, 4.2 injuries per 1000 climbing hours were reported, overuse injuries accounting for 93% of all injuries. Inflammatory tissue damages to fingers and wrists were the most common injury types. The multivariate analysis showed that overweight and practicing bouldering generally implied an increased primary injury risk, while there was a higher re‐injury risk among male climbers and a lower risk among the older climbers. The high percentage of overuse injuries implies that climbing hours and loads should be gradually and systematically increased, and climbers regularly controlled for signs and symptoms of overuse. Further study of the association between body mass index and climbing injury is warranted.

Estimated prevalences of respiratory symptoms, asthma and chronic obstructive pulmonary disease related to detection rate in primary health care

OBJECTIVE To assess the prevalence of respiratory symptoms, asthma and chronic obstructive pulmonary disease (COPD), and to relate it to an estimated detection rate in primary health care. DESIGN A two-staged study with a cross-sectional survey and a clinical validation. SETTING The adult population of Värmland, a county in Sweden. SUBJECTS 4814 persons completed the survey and 206 the confirmative validation study. MAIN OUTCOME MEASURES Prevalence of respiratory symptoms, of asthma and COPD. RESULTS More than 40% reported respiratory symptoms. Wheeze was reported by 8.0%, shortness of breath by 11.4% and sputum production by 14.1%. Smoking was more common among women than among men. The prevalence of asthma was 8.2% and COPD 2.1%. Of persons with asthma, 33% were estimated to be undiagnosed, 67% used medication and nearly 60% attended primary health care services. CONCLUSION Respiratory symptoms as well as asthma were common in this study and equivalent to earlier findings. The difference between the epidemiologically estimated prevalence of asthma and the lower detection rate in primary health care can be explained by at least three factors: persons who did not seek any care, were underdiagnosed or attended other health care providers.