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Claus F Vogelmeier,1 Kai-Michael Beeh,2 Michael Schultze,3 Nils Kossack,4 Lena M Richter,4 Jing Claussen,5 Chris Compton,6 Stephen G Noorduyn,7,8 Afisi S Ismaila,8,9 Gema Requena10 1Department of Medicine, Pulmonary and Critical Care Medicine, University Medical Centre Giessen and Marburg, Philipps-University Marburg, German Center for Lung Research (DZL), Marburg, Germany; 2Insaf Respiratory Research Institute, Wiesbaden, Germany; 3ZEG – Berlin Center for Epidemiology and Health Research GmbH, Berlin, Germany; 4WIG2 GmbH (Wissenschaftliches Institut für Gesundheitsökonomie und Gesundheitssystemforschung) - Scientific Institute for Health Economics and Health System Research, Leipzig, Germany; 5Global Medical Affairs, GSK, Munich, Germany; 6Global Medical, GSK, Brentford, UK; 7Value Evidence and Outcomes, R&D Global Medical, GSK, Mississauga, ON, Canada; 8Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; 9Value Evidence and Outcomes, R&D Global Medical, GSK, Collegeville, PA, USA; 10Value Evidence and Outcomes, R&D Global Medical, GSK, Brentford, UKCorrespondence: Gema Requena, GSK, 980 Great West Road, Brentford, Middlesex, TW8 9GS, UK, Tel +44 20 80476893, Email gema.x.requena@gsk.comPurpose: Triple therapy (long-acting muscarinic antagonist/long-acting β2-agonist/inhaled corticosteroid) is recommended for patients with chronic obstructive pulmonary disease (COPD) who experience recurrent exacerbations. Multiple-inhaler triple therapy (MITT) is associated with poor adherence and persistence. This study assessed comparative adherence and persistence to single-inhaler triple therapy (SITT) versus MITT among patients with COPD in a real-world setting in Germany.Patients and Methods: This retrospective analysis using the WIG2 benchmark database identified patients with COPD newly initiating triple therapy with MITT or SITT (fluticasone furoate/umeclidinium/vilanterol [FF/UMEC/VI] or formoterol/beclomethasone/glycopyrronium bromide [FOR/BDP/GLY]) November 2017–June 2019. Eligible patients were ≥ 35 years with 1 year’s continual insurance prior to triple therapy initiation and no previous record of triple therapy. Inverse probability of treatment weighting was used to balance baseline characteristics. Adherence was measured using proportion of days covered (PDC) at 6, 12, and 18 months post-treatment initiation; persistence (time until treatment discontinuation) was measured at 6, 12, and 18 months, with a gap of > 30 days used to define non-persistence.Results: Of 5710 patients included in the analysis (mean age 66 years), 71.4% initiated MITT and 28.6% initiated SITT (FF/UMEC/VI: 41.4%; FOR/BDP/GLY: 58.6%). Mean PDC was higher among SITT versus MITT users at all time points; at each time point, mean PDC was highest among FF/UMEC/VI users. During the first 6 months following treatment initiation, higher adherence was exhibited by FF/UMEC/VI (29%) and FOR/BDP/GLY (19%) users versus MITT users. Over the entire observation period, FF/UMEC/VI users had the highest proportion of persistent patients; at 18 months, 16.5% of FF/UMEC/VI users were persistent versus 2.3% of MITT users.Conclusion: Patients initiating SITT in Germany had significantly higher adherence and persistence compared with patients initiating MITT over 6 to 18 months following treatment initiation. Among SITT, FF/UMEC/VI users had the highest proportion of adherence and persistence.Keywords: comparative, multiple- or single-inhaler triple therapy, new-user, proportion of days covered, real-world analysis, treatment discontinuation

Aims: To identify the prevalence of cardiovascular disease (CVD) and obesity in patients with type 2 diabetes (T2D) in Germany and to evaluate if antidiabetic treatment patterns varied by comorbidity status., Materials and Methods: Patients with T2D (aged ≥18 years) were identified during the study period (2014-2020) from medical claims of 4.5 million publicly insured German residents and divided into different cohorts based on CVD and/or obesity diagnosis. Annual prevalence and incidence were estimated for each study year, while characteristics and treatments were assessed in 2020. Data were extrapolated to the German population by age and sex., Results: The prevalence of T2D in 2020 was 11.4%. Among patients with T2D, 53.0% had CVD, 39.3% had obesity, and 20.9% had CVD and obesity. Since 2014, CVD increased by 1.4%, obesity by 4.5%, and CVD with obesity by 2.7% in patients with T2D. The incidence of T2D in 2020 was 1.0% (42.9% had CVD, 37.9% had obesity, and 15.8% had CVD and obesity). Among the prevalent T2D population in 2020, 4.9% received glucagon-like peptide-1 receptor agonists (GLP-1RAs), 9.7% received sodium-glucose cotransporter-2 (SGLT2) inhibitors, and 13.0% received GLP-1 RAs and/or SGLT2 inhibitors. Of those with CVD, 12.9% received GLP-1 RAs and/or SGLT2 inhibitors (without CVD, 13.2%). Of those with obesity, 19.4% received GLP-1RAs and/or SGLT2 inhibitors (without obesity, 9.0%)., Conclusions: In this retrospective claims database study, more than two thirds of patients with T2D also had CVD, obesity, or both CVD and obesity. GLP-1 RA and SGLT2 inhibitor use remained low., (© 2024 WIG2 GmbH. Eli Lilly and Company and The Author(s). Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Introduction: The increasing adoption of artificial intelligence (AI) among college students, particularly in pharmacy education, raises ethical concerns and prompts debates on responsible usage. The promise of the potential to reduce workload is met with concerns of accuracy issues, algorithmic bias, and the lack of AI education and training. This study aims to understand pharmacy students' perspectives on the use of AI in pharmacy education., Methods: This study used an anonymous 14-question survey distributed among second, third, and fourth-year pharmacy students at four schools of pharmacy in the United States., Results: A total of 171 responses were analyzed. Demographic information included institution, class identification (P2, P3, P4), and age range. Regarding the use of AI, 43% of respondents were unaware of limitations of AI tools. Many respondents (45%) had used AI tools to complete assignments, while 42% considered it academic dishonesty. Fifty-six percent believed AI tools could be used ethically. Student perspectives on AI were varied but many expressed that it will be integral to pharmacy education and future practice., Conclusions: This study highlights the nuances of AI usage among pharmacy students. Despite limited education and training on AI, students utilized tools for various tasks. This survey provides evidence that pharmacy students are exploring the use of AI and would likely benefit from education on using AI as a supplement to critical thinking., Competing Interests: Declaration of competing interest Declaration of generative AI and AI-assisted technologies in the writing process: The authors did not use generative AI or AI-assisted technologies in the writing of this manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: This integrative scoping review explores the applications of behavioral economics within higher education, particularly, through the lens of nudging (a concept that leverages insights from economics and psychology to guide individuals' decisions subtly). The primary objective is to provide a broad overview of interventions that use behavioral economics principles and, secondarily, discuss their potential to improve pharmacy education and create a foundation for future research in this area., Findings: The review analyzed 89 studies that applied behavioral economics principles in higher education settings. Reminders and prompts were the most frequently used principles, with generally positive outcomes, especially in enrollment management. Framing, incentives, and salience also demonstrated effectiveness, depending on the context. Social norms and simplification showed mixed results, whereas priming, loss aversion, feedback, comparison, and commitment had varying degrees of success in influencing behavior., Summary: Behavioral economics principles offer valuable insights and tools for enhancing various aspects of education. The review highlights the potential for using these principles to improve student engagement, enrollment processes, and health and well-being initiatives. However, it emphasizes the importance of context-specific design and careful implementation when applying these interventions. Future research opportunities exist to further explore the applications of behavioral economics in pharmacy education and beyond., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2024 American Association of Colleges of Pharmacy. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the impact of a pharmacy student delivered presentation on prospective rural high school students' interest toward the pharmacy profession and knowledge regarding a career in pharmacy., Methods: Presentations about applying to pharmacy school, the Doctor of Pharmacy degree, and pharmacist careers were given at ten high schools across North Dakota and Minnesota by third year pharmacy students attending North Dakota State University. Each pharmacy student presenter received training to ensure that all high school students received clear and consistent information. A pre-post survey was used to understand the impact of the presentation on high school student interest and knowledge regarding a career in pharmacy. Data was analyzed using a chi-square test and McNemar's test., Results: Five hundred and eight students consented to the study and completed the pre-post surveys. Of these students, the largest group was high school juniors (number (n) = 239, 47%), followed by sophomores (n = 161, 32%), seniors (n = 104, 20%) and freshmen (n = 3, 1%). The majority of students attended school in North Dakota (n = 469, 92%). Similarly, most students planned to attend a four-year college (n = 451, 89%) and were interested in a medical/healthcare related career (n = 310, 61%). All interest and knowledge questions showed a statistically significant increase in score pre-post., Conclusion: Presentations delivered by pharmacy students to prospective rural high school students improved overall interest and knowledge regarding pharmacy school and the profession. Presentations are a useful tool for pharmacy programs to help promote their school and the profession of pharmacy., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier Inc.)

Description of the Problem. Gamification is used in pharmacy education as an innovative learning strategy to engage learners with educational content. The March Medication Madness activity used bracketology, a type of gamification not previously described in pharmacy education literature, to increase student engagement and knowledge of key disease states. The Innovation. The activity was developed for use in a capstone course during the final semester of the didactic pharmacy curriculum. Students created medication-related pearls that were placed in a tournament-style bracket. Students then completed brackets to predict the winning pearls and voted biweekly to determine the most clinically significant pearl. Student knowledge was assessed pre- and post-activity along with a post-activity perception assessment. Critical Analysis. Of the 52 student participant responses, most agreed or strongly agreed that the activity increased understanding and stimulated interest in course material, while adding a fun element to the course. There was a statistically significant increase ( P = .002) in the average percentage of multiple-choice questions students answered correctly from the pre-test (57.7% ± 1.5%) to the posttest (63.1% ± 1.9%). Pearls that received the most votes were no more likely to be associated with an increase in knowledge than pearls receiving fewer votes. Next Steps. Implementation of a bracketology activity was perceived by students as fun, engaging, and beneficial in understanding course material. However, increase in knowledge was limited. This shows the importance of structuring gamification in a way that provides educational value and underscores the need to modify the activity to promote student learning., (© Individual authors.)

Background and Purpose: The National Collegiate Athletic Association (NCAA) requires schools to provide anti-doping education to student athletes. The purpose of this project was to assess the effectiveness of student pharmacist-led education on NCAA student athletes' knowledge of banned supplements and nutritional/dietary supplements., Educational Activity and Setting: Student athletes at one Midwest public university were provided a 20-min educational presentation on banned substances and nutritional and dietary supplements delivered by two student pharmacists. Student athletes were invited to complete a knowledge assessment at baseline and after the presentation. The assessment consisted of two demographic questions and 13 knowledge questions., Findings: Two hundred thirty-three student athletes provided matched pre- and post-intervention data for analysis. There was an increase in the mean knowledge scores (13 points maximum); 9.8 (75%) before and 11.1 (85%) after the intervention. Student athletes gained more knowledge in the topic areas of stimulant medications and identification of credible drug sources. They gained less knowledge in the topic area of anabolic steroid use., Summary: Student pharmacist-led education resulted in statistically significant increases in student athlete knowledge of banned substances and nutritional/dietary supplements. The educational presentation is adaptable and easily transferable to other universities. Schools of pharmacy should consider implementing student pharmacist-led education to student athletes to meet NCAA education requirements., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To understand the process of the promotion and tenure (P&T) as experienced by faculty members in experiential education (EE)., Methods: A quantitative survey of EE faculty at any academic rank investigated the general landscape of experiences in P&T. Phenomenological qualitative interviews with faculty who currently work in EE and who achieved promotion to full professor while working within EE provided additional context. Analysis was completed using a mixed-methods approach. Incomplete survey responses were excluded., Results: Survey respondents indicated feeling different from other clinical faculty, particularly in the need to justify their work to the P&T committee (26/38; 68%). Respondents noted how challenging the P&T process was and perceived a lack of understanding of EE work among P&T committee members, chairs, and/or colleagues. In qualitative interviews, 3 themes emerged, which were characterizing a misunderstood role; navigating an unclear process with creativity and courage; and seeking outside-of-the-box mentoring., Conclusion: Experiential education faculty may require specific guidance and a thoughtful approach in tailoring their dossier for the P&T process, especially in accounting for administrative work and other unique aspects of the role. To promote inclusivity and retention of EE faculty, greater understanding of the EE role is needed as it applies to guidelines for P&T. Furthermore, EE faculty and others with unique roles should receive guidance to meaningfully apply P&T guidelines in a manner that best represents their role., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 American Association of Colleges of Pharmacy. Published by Elsevier Inc. All rights reserved.)

Objectives: The COVID-19 pandemic in South Africa introduced new societal adversities and mental health threats in a country where one in three individuals are expected to develop a psychiatric condition sometime in their life. Scientists have suggested that psychosocial stress and trauma during childhood may increase one's vulnerability to the mental health consequences of future stressors-a process known as stress sensitization. This prospective analysis assessed whether childhood adversity experienced among South African children across the first 18 years of life, coinciding with the post-apartheid transition, exacerbates the mental health impacts of psychosocial stress experienced during the 2019 coronavirus (COVID-19) pandemic (ca. 2020-2021)., Materials and Methods: Data came from 88 adults who participated in a follow-up study of a longitudinal birth cohort study in Soweto, South Africa. Childhood adversity and COVID-19 psychosocial stress were assessed as primary predictors of adult PTSD risk, and an interaction term between childhood adversity and COVID-19 stress was calculated to evaluate the potential effect of stress sensitization., Results: Fifty-six percent of adults exhibited moderate-to-severe PTSD symptoms. Greater childhood adversity and higher COVID-19 psychosocial stress independently predicted worse post-traumatic stress disorder symptoms in adults. Adults who reported greater childhood adversity exhibited non-significantly worse PTSD symptoms from COVID-19 psychosocial stress., Discussion: These results highlight the deleterious mental health effects of both childhood trauma and COVID-19 psychosocial stress in our sample and emphasize the need for greater and more accessible mental health support as the pandemic progresses in South Africa., (© 2023 The Authors. American Journal of Biological Anthropology published by Wiley Periodicals LLC.)

Background: Pregnant women were indirectly affected by the COVID-19 pandemic owing to heightened stress, fear of mother-to-child transmission of COVID-19 and the disruption of antenatal health services. Increased stress and lack of antenatal healthcare could result in an increase in adverse birth outcomes such as preterm birth or low birthweight., Objectives: Using a case-control design, to compare the prevalence of low birthweight among infants born before and during the pandemic in Soweto, South Africa., Method: Infants born before the pandemic and national lockdown were included in the control group, while infants who were in utero and born during the pandemic were included in the case group. Only infants born ≥37 weeks' gestation with no birth complications were included. Multivariable logistic regression was employed to determine whether the pandemic was associated with an increase in low birthweight. A birthweight <2.5 kg was classified as low birthweight., Results: In total, 199 mother-infant pairs were included in the control group, with 201 mother-infant pairs in the case group. The prevalence of low birthweight was 4% in the control group and 11% in the case group, with those born during the pandemic at a higher risk of being of low birthweight., Conclusion: The high prevalence of low birthweight in infants born ≥37 weeks' gestation during the pandemic could result in an increase in child stunting and poor development. Future research should measure early child development and growth in infants born during the pandemic to assess whether there is a need to intervene and provide additional support to minimise the negative effects.

Introduction: The impact of infection on infant nutritional status, body size, and growth is well documented. However, research into the impact of infection on infant body composition is limited. Greater understanding is, therefore, needed on the effects of infection in early life., Methods: Associations between a composite morbidity index consisting of the sum of the cumulative tallies for a range of symptoms representing infection and morbidity in the infants and nutritional status (height-for-age (HAZ), and weight-for-height (WHZ)), and body composition (fat-free mass (FFM), fat mass (FM), fat-free mass index (FFMI), and fat mass index (FMI)) at 6 months of age were investigated using hierarchical regression analysis., Results: The sample comprised data between birth and 6 months postnatally, of 156 infants who were a priori born healthy in Soweto, South Africa. Morbidity, over the cumulative period of birth to 6 months, was associated with lower FMI (β = -1.77) and lower FM (β = -0.61), and conversely with higher FFM (β = 0.94), in infants at 6 months. No associations were found between the morbidity index and FFMI, HAZ, and WHZ. Increased birthweight was associated with a higher FFM (β = 0.66), HAZ (β = 1.14), and WHZ (β = 0.87). Finally, safely managed sanitation facilities, representative of reduced environmental exposure to fecal-oral transmission pathways were associated with a higher HAZ (β = 1.21)., Discussion: Reduction in FMI and FM and exposure to inflammatory cytokines associated with mounting an immune response could alter phenotypic trajectories during to this period of plasticity. From a public health perspective, these results imply that it is important to intensify efforts to prevent infection in infants in the first 6 months postnatally, and that these efforts should concentrate on access to safely managed sanitation facilities., (© 2023 The Authors. American Journal of Human Biology published by Wiley Periodicals LLC.)

Background: Earlier age at menarche is associated with behavioral and noncommunicable disease risks. The influence of birth weight (BW) (intrauterine) and postnatal growth on age at menarche is not well studied in low- and middle-income countries (LMICs)., Objective: Therefore, we investigated these associations in 5 LMIC birth cohorts., Methods: We analyzed data from Brazil, Guatemala, India, the Philippines, and South Africa (n = 3983). We derived stunting (< -2 SD scores) at 24 mo using the WHO child growth standards. We generated interaction terms with categorized BW and conditional weight (lighter < 0 or heavier ≥ 0), and height (shorter < 0 or taller ≥ 0) z-scores. We categorized early-, modal-, and late-onset menarche and used multilevel ordinal regression. We used multilevel linear regression on continuous age at menarche., Results: Mean age at menarche was 12.8 y (95% CI: 12.7 12.9). BW was not associated with age at menarche. Conditional height at 24 mo and mid-childhood (OR: 1.35; 95% CI: 1.27, 1.44 and 1.32; 1.25, 1.41, respectively) and conditional weight at 24 mo and mid-childhood (OR: 1.15; 1.08, 1.22 and 1.18; 1.11, 1.25, respectively) were associated with increased likelihood of early-onset menarche. Being heavier at birth and taller at 24 mo was associated with a 4-mo (95% CI: 0.8, 7.6) earlier age at menarche than being lighter at birth and shorter at 24 mo. Being heavier at birth but lighter in mid-childhood was associated with a 3-mo (95% CI: 0.8, 4.8) later age at menarche than being lighter at birth and mid-childhood. Age at menarche was 7 mo later in stunted than nonstunted girls., Conclusion: Age at menarche is inversely related to relative weight gain but also to rapid linear growth among those born shorter but remained stunted, and those born taller and grew excessively. These findings do not deter the global health goal to reduce growth faltering but emphasize the potential adverse effects of an obesogenic environment on adolescent development., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Providing young children with universal access to preprimary education (PPE) is considered a powerful tool for human capital development and eliminating the intergenerational transmission of poverty. To remove household financial barrier for achieving universal PPE, this study proposed a measure to identify households incurring 'heavy financial burdens from paying for PPE' (HBPPE) and conducted a case study in China., Methods: Using nationally representative data in 2019, we estimated the percentage of households with HBPPE (spent 7% or more of their total annual expenditure) and associated socioeconomic inequalities. We also applied a three-level logit regression model to investigate the factors associated with the probabilities of households incurring HBPPE., Results: Half of the sampled households spent 7% or more of their expenditures on PPE. Households in the lowest wealth quintile (54%) or households with children attending private PPE (55%) had higher percentages of HBPPE than households in other wealth quintiles (eg, 51% in the highest wealth quintile) or households with children attending public kindergartens (41%). Logit regression analysis shows that the poorest households and households with children attending private kindergarten were more likely to incur HBPPE than their counterparts., Conclusion: To ensuring universal access to PPE in China, future policy should consider increasing the enrolment of children from low-income families in public kindergartens and increasing governmental investments in low-income households by subsidising children attending PPE., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: None.

Objective: We examined associations among serial measures of linear growth and relative weight with adult body composition., Design: Secondary data analysis of prospective birth cohort studies., Settings: Six birth cohorts from Brazil, Guatemala, India, the Philippines and South Africa., Participants: 4173 individuals followed from birth to ages 22-46 years with complete and valid weight and height at birth, infancy, childhood and adolescence, and body composition in adult life., Exposures: Birth weight and conditional size (standardised residuals of height representing linear growth and of relative weight representing weight increments independent of linear size) in infancy, childhood and adolescence., Primary Outcome Measures: Body mass index, fat mass index (FMI), fat-free mass index (FFMI), fat mass/fat-free mass ratio (FM/FFM), and waist circumference in young and mid-adulthood., Results: In pooled analyses, a higher birth weight and relative weight gains in infancy, childhood and adolescence were positively associated with all adult outcomes. Relative weight gains in childhood and adolescence were the strongest predictors of adult body composition (β (95% CI) among men: FMI (childhood: 0.41 (0.26 to 0.55); adolescence: 0.39 (0.27 to 0.50)), FFMI (childhood: 0.50 (0.34 to 0.66); adolescence: 0.43 (0.32 to 0.55)), FM/FFM (childhood: 0.31 (0.16 to 0.47); adolescence: 0.31 (0.19 to 0.43))). Among women, similar patterns were observed, but, effect sizes in adolescence were slightly stronger than in childhood. Conditional height in infancy was positively associated with FMI (men: 0.08 (0.03 to 0.14); women: 0.11 (0.07 to 0.16)). Conditional height in childhood was positively but weakly associated with women's adiposity. Site-specific and sex-stratified analyses showed consistency in the direction of estimates, although there were differences in their magnitude., Conclusions: Prenatal and postnatal relative weight gains were positive predictors of larger body size and increased adiposity in adulthood. A faster linear growth in infancy was a significant but weak predictor of higher adult adiposity., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Interactions between the MAOA uVNTR and rearing environment are suggested to influence the developmental manifestations of childhood internalizing and externalizing behavior. However, few studies in the MAOA literature have included continental African children, or focused on non-clinical samples. We explored the main and interactive effects of the MAOA uVNTR (high and low activity alleles) in Black South African male ( n  = 478) and female ( n  = 540) children who were part of the longitudinal Birth to Twenty Plus cohort. Historical data on birth weight, gestational age at delivery, socioeconomic status, and maternal education were combined with genotypic information and analyzed using regression modeling. We found no significant main effects for the MAOA uVNTR on childhood behavior in either sex. A significant interaction ( p = .04) was identified between MAOA and maternal education, suggesting that externalizing behavior in boys carrying a low activity MAOA allele varied in direct proportion to the education levels of their mothers. However, the model fit failed to reach significance, possibly due to our inclusion of only non-clinical pre-pubertal males. No significant interactions were detected for female children. Our findings lend tentative credibility to the Environmental Sensitivity metaframework, which suggests that MAOA is an important plasticity factor in childhood development.

Background: South Africa's rates of psychiatric morbidity are among the highest in sub-Saharan Africa and are foregrounded by the country's long history of political violence during apartheid. Growing evidence suggests that in utero stress exposure is a potent developmental risk factor for future mental illness risk, yet the extent to which the psychiatric effects of prenatal stress impact the next generation are unknown. We evaluate the intergenerational effects of prenatal stress experienced during apartheid on psychiatric morbidity among children at ages 17-18 and also assess the moderating effects of maternal age, social support, and past household adversity., Methods: Participants come from Birth-to-Twenty, a longitudinal birth cohort study in Soweto-Johannesburg, South Africa's largest peri-urban township which was the epicentre of violent repression and resistance during the final years of the apartheid regime. Pregnant women were prospectively enrolled in 1990 and completed questionnaires assessing social experiences, and their children's psychiatric morbidity were assessed at ages 17-18., Results: Full data were available from 304 mother-child pairs in 2007-8. Maternal prenatal stress in 1990 was not directly associated greater psychiatric morbidity during at ages 17-18. Maternal age and past household adversity moderated the intergenerational mental health effects of prenatal stress such that children born to younger mothers and late adolescent/young adult children experiencing greater household adversity exhibited worse psychiatric morbidity at ages 17-18. Social support did not buffer against the long-term psychiatric impacts of prenatal stress., Conclusions: Greater prenatal stress from apartheid predicted adverse psychiatric outcomes among children born to younger mothers and adolescents/young adults who experienced greater concurrent stress. Our findings suggest that prenatal stress may affect adolescent mental health, have stress-sensitising effects, and represent possible intergenerational effects of trauma experienced under apartheid in this sample., (© 2022 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Background: Nutrition is important for growth and brain development and therefore cognitive ability. Growth faltering in early childhood, an important indicator of early adversity, is associated with poorer developmental outcomes, some into adulthood, but this association probably reflects early-life deprivation. We aimed to investigate the associations between early-life stature, child IQ, and adult IQ., Methods: In this cohort study, we used prospective longitudinal data collected in four birth cohorts from Brazil (born in 1993), Guatemala (born in 1969-77), the Philippines (born in 1983-84), and South Africa (born in 1990). Using multivariable linear models, we estimated the relative contributions of early-life stature, child IQ, and schooling (highest school year completed) to adult IQ, including interaction effects among the early-childhood measures and schooling., Findings: We included 2614 individuals in the analysis. Early-life stature was associated with adult IQ (range across eight site-by-sex groups -0·14 to 3·17 IQ points) and schooling (-0·05 to 0·77 years) per height-for-age Z-score. These associations were attenuated when controlling for child IQ (-0·86 to 1·72 for adult IQ and -0·5 to 0·60 for schooling). The association of early-life stature with adult IQ was further attenuated when controlling for schooling (-1·86 to 1·21). Child IQ was associated with adult IQ (range 3·91 to 10·02 points) and schooling (0·25 to 1·30 years) per SD of child IQ in all groups; these associations were unattenuated by the addition of early-life stature to the models. The interaction between schooling and child IQ, but not that between schooling and early-life stature, was positively associated with adult IQ across groups., Interpretation: The observed associations of early-life stature with adult IQ and schooling varied across cohorts and sexes and explained little variance in adult IQ beyond that explained by child IQ. These findings suggest that interventions targeted at growth for health and early development are important. Our results are consistent with the inference that improving long-term cognitive outcomes might require interventions that more specifically target early cognitive ability., Funding: Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objective. To design and assess the use of a pharmacy student-delivered preceptor development program. Methods. A student-delivered preceptor development program was developed to ensure all preceptors received documented preceptor development. A menu of discussion topics and associated teaching sheets were created by the school's office of experiential education. On each rotation, advanced pharmacy practice experience (APPE) students led discussions with their preceptors on a topic chosen by the preceptor and submitted documentation of the education. Preceptors answered a survey related to the amount of information and time required for the program, their preference for different formats of preceptor development, one important thing they learned through the program, and future development topics of interest. Students were interviewed regarding their perceptions and use of the program. Results. A novel student-delivered preceptor development program resulted in documentation of preceptor development for all APPE rotations. Seventy-nine preceptors (31% response rate) participated in the survey. In their responses, preceptors generally agreed that they were able to customize their development and incorporate what they learned into practice, and that the program had a convenient format and was valuable for preparing students to be future preceptors. Students reported that the program improved their confidence in communicating with a supervisor and prepared them for precepting. Conclusion. A student-delivered preceptor development program improved documented preceptor development. The program allowed preceptors to customize development opportunities in a convenient format. It was perceived positively by preceptors who would recommend the program to other schools of pharmacy., (© 2023 American Association of Colleges of Pharmacy.)

Life history theory emphasises plasticity in developmental and biological programming where conditions in early life, lead to long-term consequences for health and wellbeing. Studies linking water, sanitation, and hygiene, nutrition, and child growth and development have emphasised the optimisation of linear growth as a key metric for the evaluation of intervention efficacy. Life history characteristics pertaining to human growth and phenotypic plasticity, suggest that different developmental outcomes in early childhood may be responsive to different stimuli at different ages. Energy utilisation by the human brain, from birth through childhood, accounts for a disproportionate percentage of the resting metabolic rate. Undernutrition in early life, and its relative resultant energy deficiency, may trigger adaptive physiological mechanisms prioritising brain growth at the expense of body growth. Emphasis placed on linear growth may have impeded the significance of WASH due to excluding aspects of child development beyond height/weight. We propose that incorporating evolutionary public health and life history theory perspectives, allows for the identification of age-appropriate biological outcomes and WASH indicators, while anticipating the timing and life-course suitability of the interventions being operationalised. Finally, integrating reflections regarding context allows for the development of transformative WASH interventions.

Effective teamwork in the online environment is essential to patient care and safety. The need for training health professionals to work together on a virtual interprofessional team has become even more important since the start of the COVID-19 pandemic as telehealth, or the provision of virtual healthcare to patients, has become more common. This resource describes the development of an online escape room activity using free online resources. The activity aimed to enhance health profession students' abilities to communicate effectively, work together to complete a task, and develop knowledge of the unique roles of healthcare team members in a course dedicated to interprofessional education. Teams of five to seven students met online and completed seven puzzles to escape a virtual room. Results obtained from the pre-post surveys of 176 students across six disciplines showed the activity aided in increasing participants perceptions of their ability to communicate respectfully and work together to complete a task, while developing knowledge of the unique roles of members of the healthcare team, all components of the Interprofessional Education Collaborative (IPEC) Core Competencies. This activity lays the groundwork for collaborative, interprofessional activities, such as telehealth, which students will be exposed to in their futures, and the results infer that the activity can help to build collaboration among team members, even team members that are not in the same physical space., (© 2022 Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic and governments' attempts to contain it are negatively affecting young children's health and development in ways we are only beginning to understand and measure. Responses to the pandemic are driven largely by confining children and families to their homes. This study aims to assess the levels of and associated socioeconomic disparities in household preparedness for protecting young children under the age of five from being exposed to communicable diseases, such as COVID-19, in low- and middle-income countries (LMICs)., Methods: Using data from nationally representative household surveys in 56 LMICs since 2016, we estimated the percentages of young children under the age of five living in households prepared for communicable diseases (e.g., COVID-19) and associated residential and wealth disparities at the country- and aggregate-level. Preparedness was defined on the basis of space for quarantine, adequacy of toilet facilities and hand hygiene, mass media exposure at least once a week, and phone ownership. Disparities within countries were measured as the absolute gap in two domains-household wealth and residential area - and compared across regions and country income groups., Results: The final data set included 766,313 children under age five. On average, 19.4% of young children in the 56 countries lived in households prepared for COVID-19, ranging from 0.6% in Ethiopia in 2016 to 70.9% in Tunisia in 2018. In close to 90% of countries (50), fewer than 50% of young children lived in prepared households. Young children in rural areas or in the poorest households were less likely to live in prepared households than their counterparts., Conclusions: A large portion of young children under the age of five in LMICs were living in households that did not meet all preparedness guidelines for preventing COVID-19 and caring for patients at home. This study highlights the need to ensure all families in LMICs have the means to prevent the spread of the pandemic or other communicable illnesses to young children during pandemics., (© 2022. The Author(s).)

Caregivers are often concerned about baby behaviours. Without adequate counselling, parental response can lead to altering infant feeding and jeopardizing breastfeeding. We conducted a systematic review to assess the evidence about the influence of baby behaviours perceived as problematic (crying, sleep waking and posseting) on infant feeding decisions during the first 6 months of life (self-reported milk insufficiency, breastfeeding duration and introduction of formula). The review focused on quantitative studies published in English, Portuguese or Spanish without date restriction. The search was designed with the support of a medical librarian and conducted in seven databases. Data were managed in Covidence and risk of bias was assessed through the Johanna Briggs Institute critical appraisal checklists. Synthesis of the literature was guided by a conceptual model of the impact of baby behaviours on caregivers feeding practices. We retrieved and reviewed 4312 titles/abstracts and selected 22 for review; 10 were purely descriptive and 12 were cross-sectional, prospective and quasi-experimental studies. Although studies from diverse regions were included in the review, more than half were from high-income countries. All studies reported that baby behaviours affect feeding decisions, the most common baby behaviours studied were crying and fussiness, and the studies suggested relationships with lactation problems and reports of milk insufficiency, maternal breastfeeding confidence, breastfeeding duration and discontinuation, and introduction of formula. There are many factors that lead to perceiving baby behaviours as problematic and there is a need to provide anticipatory guidance to parents and caregivers, starting in pregnancy and counselling through well-trained health providers., (© 2022 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

The survival and nutrition of children and, to a lesser extent, adolescents have improved substantially in the past two decades. Improvements have been linked to the delivery of effective biomedical, behavioural, and environmental interventions; however, large disparities exist between and within countries. Using data from 95 national surveys in low-income and middle-income countries (LMICs), we analyse how strongly the health, nutrition, and cognitive development of children and adolescents are related to early-life poverty. Additionally, using data from six large, long-running birth cohorts in LMICs, we show how early-life poverty can have a lasting effect on health and human capital throughout the life course. We emphasise the importance of implementing multisectoral anti-poverty policies and programmes to complement specific health and nutrition interventions delivered at an individual level, particularly at a time when COVID-19 continues to disrupt economic, health, and educational gains achieved in the recent past., Competing Interests: Declaration of interests REB serves on the Board of Vitamin Angels, a non-profit charitable organisation supporting maternal and child nutrition services in LMICs. AS and ADS report grants from Bill and Melinda Gates Foundation. AS reports grants from the Wellcome Trust. ZAB reports grants from the International Development Research Centre (reproductive, maternal, newborn, child, and adolescent health in conflict settings: case studies to inform implementation of interventions) and Countdown to 2030–UNICEF. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood., Competing Interests: Declaration of interests REB serves on the Board of Directors of Vitamin Angels, a non-profit charitable organisation supporting maternal and child nutrition services in low-income and middle-income countries. ME reports a grant from AstraZeneca for the Young Health Programme, and personal fees from Prudential, outside the submitted work. REB, FV, LH, LL, ADS, DYo, and DYe report grants from the Bill & Melinda Gates Foundation. LH and DYo report grants from USAID, outside the submitted work., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Although early life factors are associated with increased suicide risk in youth, there is a dearth of research on these associations for individuals growing up in disadvantaged socioeconomic contexts, particularly in low- and middle-income countries (LMICs). We documented the association between individual, familial, and environmental factors in childhood with suicidal ideation among South African youth., Methods and Findings: We used data from 2,020 participants in the Birth to Twenty Plus (Bt20+) study, a South African cohort following children born in Soweto, Johannesburg from birth (1990) to age 28 years (2018). Suicidal ideation was self-reported at ages 14, 17, 22, and 28 years, and the primary outcome of interest was suicidal ideation reported at any age. We assessed individual, familial, and socioeconomic characteristics at childbirth and during infancy, adverse childhood experiences (ACEs) between ages 5 and 13 years, and externalizing and internalizing problems between 5 and 10 years. We estimated odds ratios (ORs) of suicidal ideation for individuals exposed to selected childhood factors using logistic regression. Lifetime suicidal ideation was reported by 469 (23.2%) participants, with a 1.7:1 female/male ratio. Suicidal ideation rates peaked at age 17 and decreased thereafter. Socioeconomic adversity, low birth weight, higher birth order (i.e., increase in the order of birth in the family: first, second, third, fourth, or later born child), ACEs, and childhood externalizing problems were associated with suicidal ideation, differently patterned among males and females. Socioeconomic adversity (OR 1.13, CI 1.01 to 1.27, P = 0.031) was significantly associated with suicidal ideation among males only, while birth weight (OR 1.20, CI 1.02 to 1.41, P = 0.03), ACEs (OR 1.11, CI 1.01 to 1.21, P = 0.030), and higher birth order (OR 1.15, CI 1.07 to 1.243, P < 0.001) were significantly associated with suicidal ideation among females only. Externalizing problems in childhood were significantly associated with suicidal ideation among both males (OR 1.23, 1.08 to 1.40, P = 0.002) and females (OR 1.16, CI 1.03 to 1.30, P = 0.011). Main limitations of the study are the high attrition rate (62% of the original sample was included in this analysis) and the heterogeneity in the measurements of suicidal ideation., Conclusions: In this study from South Africa, we observed that early life social and environmental adversities as well as childhood externalizing problems are associated with increased risk of suicidal ideation during adolescence and early adulthood., Competing Interests: The authors have declared that no competing interests exist.

The Accreditation Council for Pharmacy Education (ACPE) requires pharmacy students to complete 1440 hours of advanced pharmacy practice experiences (APPEs). The majority of all APPE hours should be in direct patient care; however, non-patient care electives can also help to prepare students to become practice ready as well as allow them to explore areas of interest. Many pharmacy schools offer elective academic rotations, but an office of experiential education (OEE) academic rotation offers a unique academic elective. This Commentary describes an OEE APPE and includes the views of a preceptor and a pharmacy student regarding the experience. A detailed list of activities for an OEE APPE that can be easily duplicated by other schools is provided. The OEE APPE can be completed online or in-person, creating greater flexibility for administration., (© 2022 American Association of Colleges of Pharmacy.)

Background and Study:  The sacroiliac joint (SIJ) may be the primary source of pain in 15 to 25% of patients with axial low back pain. Furthermore, 75% of patients who have had fusion surgery develop SIJ pain within 10 years. Treatment options include SIJ blocks, radiofrequency (RF) denervation, and fusion. The RF techniques range from ablation of the nerves supplying the joint, creating lesions to the joint itself, or a combination of both techniques. However, different clinical studies could only identify a limited or, in some cases, no effect in decreasing of pain intensity and duration of the effect., Methods:  In this retrospective study, we selected 23 patients with SIJ pain, with a duration of more than 12 months and a 50% pain reduction on the Numeric Rating Scale (NRS) after diagnostic block. All patients received endoscopic ablation of the medial branch L5/S1 and the lateral branches, exiting the sacral foramina on S1/S2 and S2/S3 on both sides while using only one incision on each side. Telephone interviews were conducted with all patients. The outcome was determined with Odom's criteria, percent reduction NRS, subjective assessment of the patient, and duration of the effect., Results:  According to Odom's criteria, 79% of the patients showed acceptable to excellent results and confirmed that denervation helped them to manage their daily lives better. The average pain reduction in the responder group was 57% with an average duration of 13.4 months., Conclusion:  In this retrospective study, we could demonstrate the practicability and effectiveness of endoscopic SIJ denervation in the treatment of SIJ pain using only one incision for three levels on each side. Further studies should investigate if this procedure is more effective than percutaneous RF., Competing Interests: Dr. Woiciechowsky reports grants from RiwoSpine, during the conduct of the study, and personal fees from presentations and workshops, outside the submitted work., (Thieme. All rights reserved.)

Human capital-that is the cumulative abilities, education, social skills, and mental and physical health one possesses-is increasingly recognized as key to the reduction of inequality in societies. Adverse childhood experiences have been linked to a range of human capital indicators, with the majority of research in high-income, western settings. This study aims to examine the link between adverse childhood experiences and adult human capital in a South African birth cohort and to test whether associations differ by measurement of adversity. Secondary analysis of data from the Birth to Thirty study was undertaken. Exposure data on adversity was collected prospectively throughout childhood and retrospectively at age 22. Human capital outcomes were collected at age 28. Adversity was measured as single adverse experiences, cumulative adversity, and clustered adversity. All three measurements of adversity were linked to poor human capital outcomes, with risk for poor human capital increasing with the accumulation of adversity. Adversity was clustered by quantity (low versus high) and type (household dysfunction versus abuse). Adversity in childhood was linked to a broad range of negative outcomes in young adulthood regardless of how it was measured. Nevertheless, issues of measurement are important to understand the risk mechanisms that underlie the association between adversity and poor human capital.

Background: Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis., Methods: We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised., Findings: Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras., Interpretation: Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Subjective social status (SSS, perception of social position relative to a frame of reference) has been associated with physical, mental and socio-emotional wellbeing. However, these associations may be susceptible to unmeasured confounding by life course objective socio-economic position (SEP; such as wealth, education and employment) and life satisfaction., Purpose: To estimate the association of position on ladders of perceived community respect and perceived economic status with weight, distress and wellbeing, independent of objective SEP in cohorts from three low and middle-income countries., Methods: We used data from birth cohorts in Guatemala (n = 1258), Philippines (n = 1323) and South Africa (n = 1393). We estimated the association of perceived community respect and perceived economic status with body mass index (kg/m 2 ), the World Health Organization's Self-Reported Questionnaire-20 (SRQ-20) for psychological distress, and Lyubomirsky's Subjective Happiness Scale. We estimated these associations using robust linear regression models adjusting for indicators of life course objective SEP, early life characteristics, adult covariates, and life satisfaction., Results: Participants in South Africa (age 27-28y) rated themselves higher on average for both the respect (7 vs 5 in Guatemala and 6 in Philippines) and economic (5 vs 3 in Guatemala and 4 in Philippines) ladder measures. Position on neither community respect nor economic ladders were associated with BMI or psychological distress. Higher position on community respect (Guatemala: 0.03, 95%CI: 0.01, 0.04; Philippines: 0.03, 95% CI: 0.02, 0.05; South Africa: 0.07, 95%CI: 0.04, 0.09) and economic (Guatemala: 0.02, 95%CI: 0, 0.04; Philippines: 0.04, 95%CI: 0.02, 0.07; South Africa: 0.07, 95%CI: 0.04, 0.10) ladders were associated with greater happiness., Conclusions: Subjective social status showed small but consistent associations with happiness in birth cohorts independent of life-course SEP., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Key Messages: Benefits for mothers and children can be achieved through the successful integration of an early childhood development programme into PMTCT Option B+ services in Malawi.Our study based on in-depth interviews with 62 mothers indicated that such an approach is feasible and acceptable.Participating mothers reported that the integration of the early childhood development component improved their confidence and they believed it improved their parenting;led to improved relationships with health care providers;increased the engagement of fathers and support from others in the family;helped mothers build a new social network and support system through the peer engagement components;reduced the risk of stigmatization in the health care setting.

Background: Temporally-harmonized asset-based measures of wealth can be used to study the association of life-course wealth exposures in the same scale with health outcomes in low- and middle-income countries (LMICs). The within-individual longitudinal stability of asset-based indices of wealth in LMICs is poorly understood., Methods: Using data from five birth cohorts from three continents, we developed temporally-harmonized asset indices over the life course through polychoric principal component analysis of a common set of assets collected consistently over time (18 years in Brazil to 50 years in Guatemala). For each cohort, we compared the harmonized index to cross-sectional indices created using more comprehensive asset measures using rank correlations. We evaluated the rank correlation of the harmonized index in early life and adulthood with maternal schooling and own attained schooling, respectively., Results: Temporally-harmonized asset indices developed from a consistently-collected set of assets (range: 10 in South Africa to 30 in Philippines) suggested that mean wealth improved over time for all birth cohorts. Cross-sectional indices created separately for each study wave were correlated with the harmonized index for all cohorts (Brazil: r = 0.78 to 0.96; Guatemala: r = 0.81 to 0.95; India: 0.75 to 0.93; Philippines: r = 0.92 to 0.99; South Africa: r = 0.84 to 0.96). Maternal schooling (r = 0.15 to 0.56) and attained schooling (r = 0.23 to 0.53) were positively correlated with the harmonized asset index in childhood and adulthood respectively., Conclusions: Temporally-harmonized asset indices displayed coherence with cross-sectional indices as well as construct validity with schooling., Competing Interests: None declared., (© 2021 The Authors.)

Purpose: We investigated associations between adolescent internalizing and externalizing problems and adult human capital in a non-Western setting. Little is known about adolescent mental health problems and adult outcomes in low- and middle-income countries, many of which are characterized by high levels of adversities., Methods: Data came from the Birth to Twenty Plus cohort, started in Soweto, Johannesburg, South Africa, in 1990. We estimated associations of internalizing and externalizing problems at the age of 14 years with self-reported educational, employment, welfare receipt, psychosocial (psychological distress, criminality, substance use), interpersonal (social isolation, intimate partner violence, partnership status), and HIV outcomes at the age of 28 years., Results: Adolescents with high internalizing problems were less likely to have completed secondary school or be formally employed and more likely to report psychological distress. Those with high levels of externalizing problems were more likely to report adulthood criminal activity and substance use. We found significant associations between internalizing and externalizing problems and intimate partner violence. There was no association between adolescent mental health problems and welfare receipt, HIV, social isolation, or partnership status. Men were more likely to report incomplete secondary education, no formal employment, criminality and substance use, social isolation, and no serious relationship, whereas women were more likely to experience psychological distress and be in receipt of welfare., Conclusions: Adolescent mental health problems are associated with long-term negative adult functioning under varying socioeconomic conditions. Interventions to recognize and address youth mental health problems in low- and middle-income countries are needed to avert serious adverse adult and societal consequences., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

A recent Nature article modelled within-country inequalities in primary, secondary, and tertiary education and forecast progress towards Sustainable Development Goal (SDG) targets related to education (SDG 4). However, their paper entirely overlooks inequalities in achieving Target 4.2, which aims to achieve universal access to quality early childhood development, care and preschool education by 2030. This is an important omission because of the substantial brain, cognitive and socioemotional developments that occur in early life and because of increasing evidence of early-life learning's large impacts on subsequent education and lifetime wellbeing. We provide an overview of this evidence and use new analyses to illustrate medium- and long-term implications of early learning, first by presenting associations between pre-primary programme participation and adolescent mathematics and science test scores in 73 countries and secondly, by estimating the costs of inaction (not making pre-primary programmes universal) in terms of forgone lifetime earnings in 134 countries. We find considerable losses, comparable to or greater than current governmental expenditures on all education (as percentages of GDP), particularly in low- and lower-middle-income countries. In addition to improving primary, secondary and tertiary schooling, we conclude that to attain SDG 4 and reduce inequalities in a post-COVID era, it is essential to prioritize quality early childhood care and education, including adopting policies that support families to promote early learning and their children's education., (© 2021. The Author(s).)

Introduction: This study determined the need to calibrate preceptors' use of levels of entrustment (LOE) in the evaluation of students performing entrustable professional activities (EPAs)., Methods: Two introductory and four advanced pharmacy practice experience-focused cases were developed which described a fictional student, a practice site, and timing of a rotation. The cases included EPA-based tasks assigned to the student. Participants were to assign a LOE to the student for each EPA-based task., Results: Sixty of 317 preceptors participated in the study. Statistically significant differences in mean assigned LOE were found between preceptors by age (P < .05); between preceptors with differences in residency training (P < .05); and between preceptors who spent differing amounts of time with experiential students daily (P < .05)., Conclusions: Differences in assigned LOE were found based upon preceptor age, completion of a residency, and daily hours spent with experiential students. However, these differences did not result in changes to whether the student would pass or fail the rotation. Findings suggest that preceptors are consistent in assigning LOE to EPA-based tasks performed by students. In addition, preceptor development programming appears to be effective in establishing a standardized understanding of LOE among preceptors., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Evidence has identified the detrimental effects that adverse childhood experiences (ACEs) have on outcomes across the life course. We assess associations between prospective and retrospective ACEs and mental health in young adulthood and the influence of recent stressors., Methods: Secondary analysis of a sample of 1592 young adults from the Birth to Twenty Plus cohort, from 1990 to 2013, were assessed throughout their first 18 years for prospective ACEs. Retrospective ACEs and an assessment of mental health were collected at the 22-23-year data point., Findings: Prospective physical and sexual abuse are associated with an increased risk of depression (OR 1·7 [95% CI 1·37-1·93, p  = 0·034], and OR 1·8 [95% CI 1·27-2·07, p  = 0·018], respectively). Retrospective emotional abuse/neglect is associated with increased anxiety (OR 1·8 [95% CI 1·32-2·36, p  = 0·000]), depression (OR 1·6 [95% CI 1·08-2·25, p  = 0·018]) and overall psychological distress (OR 1·6 [95% CI 1·18-2·17, p  = 0·002]). Prospectively reporting four or more ACEs is associated with a twofold increase in risk for overall psychological distress (OR 2·2 [95% CI 1·58-3.12, p  = 0·008]). Retrospectively reporting four or more ACEs is associated with increased likelihood of somatization ( p  = 0·004), anxiety ( p  = 0·002), depression ( p  = 0·021), and overall psychological distress ( p  = 0·005)., Interpretation: Both individual and combined retrospective and prospective ACEs are related to mental health in young adulthood. Recent stressors reinforce this relationship; the likelihood of those who report more ACEs experiencing psychological distress increases when adjusting for recent stressors., Funding: Wellcome Trust (UK), South African Medical Research Council, Human Sciences Research Council, University of the Witwatersrand and supported by the DSI-NRF Centre of Excellence in Human Development., Competing Interests: The authors declare no competing interests., (© 2021 The Author(s).)

Background: Growth faltering has been associated with poor intellectual performance. The relative strengths of associations between growth in early and in later childhood remain underexplored., Objectives: We examined the association between growth in childhood and adult human capital in 5 low- and middle-income countries (LMICs)., Methods: We analyzed data from 9503 participants in 6 prospective birth cohorts from 5 LMICs (Brazil, Guatemala, India, the Philippines, and South Africa). We used linear and quasi-Poisson regression models to assess the associations between measures of height and relative weight at 4 age intervals [birth, age ∼2 y, midchildhood (MC), adulthood] and 2 dimensions of adult human capital [schooling attainment and Intelligence Quotient (IQ)]., Results: Meta-analysis of site- and sex-specific estimates showed statistically significant associations between size at birth and height at ∼2 y and the 2 outcomes (P < 0.001). Weight and length at birth and linear growth from birth to ∼2 y of age (1 z-score difference) were positively associated with schooling attainment (β: 0.13; 95% CI: 0.08, 0.19, β: 0.17; 95% CI: 0.07, 0.32, and β: 0.25, 95% CI: 0.10, 0.40, respectively) and adult IQ (β: 0.74, 95% CI: 0.35, 1.14, β: 0.73, 95% CI: 0.35, 1.10, and β: 1.52, 95% CI: 0.96, 2.08, respectively). Linear growth from age 2 y to MC and from MC to adulthood was not associated with higher school attainment or IQ. Change in relative weight in early childhood, MC, and adulthood was not associated with either outcome., Conclusions: Linear growth in the first 1000 d is a predictor of schooling attainment and IQ in adulthood in LMICs. Linear growth in later periods was not associated with either of these outcomes. Changes in relative weight across the life course were not associated with schooling and IQ in adulthood., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Importance: Few studies from low-and-middle income countries have investigated long-term associations between maternal postnatal depression and offspring internalizing (ie, depressive and anxiety) symptoms, and none have investigated interactions in this association., Objective: To investigate the association between maternal postnatal depression and offspring internalizing symptoms from adolescence to adulthood and the interaction with exposure to socioeconomic adversity and with the child's sex., Design, Setting, and Participants: This secondary analysis used data from Birth to Twenty Plus (BT20+), a prospective birth cohort study of children born in Soweto, South Africa, and followed up until age 28 years. Data were collected from 1990 to 2018, and data were analyzed for this study from February 16 through December 15, 2020., Exposures: Maternal postnatal depression self-reported by mothers 6 months after childbirth., Main Outcomes and Measures: The main outcome was offspring internalizing symptoms, assessed at offspring ages 14 years, 22 years, and 28 years and modeled longitudinally. Participants with the highest probability of experiencing high internalizing symptoms (ie, those in the top 20% of the distribution) from age 14 to 28 years were categorized as belonging to the high internalizing symptoms trajectory (vs the low trajectory). Socioeconomic adversity was measured with an index (continuous variable) including low maternal education, household crowding, low assets, and low maternal age. This variable was further stratified into more than 1 SD above the mean index, more than 1 SD below the mean index, and from 1 SD below to 1 SD above the mean index to conduct subgroup analyses. Associations were investigated using multivariable regression models., Results: Among 1087 participants born in Soweto, South Africa (543 [50.0%] male participants; 544 [50.0%] female participants), 118 individuals (10.8%) showed a high trajectory of internalizing symptoms from age 14 to 28 years vs 969 individuals (89.1%) with a low trajectory. Children exposed to maternal postnatal depression had statistically significantly increased odds of following the high trajectory (adjusted odds ratio [aOR] per 1-SD increase in maternal postnatal depression, 1.20; 95% CI, 1.02-1.41). This increase in odds differed by exposure to socioeconomic adversity and by child sex: for male participants, the increase in odds was greater in a context of higher vs lower socioeconomic adversity (eg, for >1 SD above the mean: aOR, 3.28; 95% CI, 1.06-10.14 vs for >1 SD below the mean: aOR, 0.98; 95% CI, 0.64-1.50; P for interaction = .12), while for female participants, the increase in odds was greater in a context of lower vs higher socioeconomic adversity (eg, for >1 SD below the mean: aOR, 1.82; 95 % CI, 1.12-2.98 vs for >1 SD above the mean: aOR, 0.59; 95 % CI, 0.30-1.17; P for interaction = .002) (P for 3-way interaction = .003)., Conclusions and Relevance: This study found that postnatal depression was associated with higher odds of persistently increased internalizing symptoms among offspring from adolescence to adulthood in a middle-income country, with variation by socioeconomic adversity and sex. These findings suggest that better understanding of these associations is needed to implement targeted interventions and maximize the impact of public health initiatives aimed at breaking the intergenerational transmission of mental health problems.

Purpose: In high-income countries, early and rapid pubertal development is consistently associated with poor adjustment and increased risk behavior in adolescence. This study contributes to the meager knowledge of these associations in lower income countries., Methods: We used longitudinal data from 1,784 urban black South Africans in the Birth to Twenty Plus cohort. We used regression analyses to assess associations between age at menarche and latent classes of pubertal timing and tempo and adolescent internalizing and externalizing emotional and behavioral problems, eating attitudes, and patterns of health risk behavior initiation., Results: Relatively earlier and faster pubertal timing and tempo were associated with increased health risk behavior initiation (e.g., adjusted odds ratio [95% confidence interval] high- vs. low-risk pattern = 5.7 [1.7, 19.06] for male genital development; adjusted odds ratio = 3.45 [1.13, 10.49] for female breast development). Among males, earlier and faster pubertal timing and tempo were associated with increased externalizing problems in early adolescence and increased oppositional defiant problems in midadolescence, whereas later and slower pubertal timing and tempo were associated with decreases. Among females, earlier and faster pubertal timing and tempo were associated with increased internalizing and externalizing problems in midadolescence and increased dieting behaviors in early and late adolescence (β [95% confidence interval] = 2.51 [.87, 4.15] for pubic hair development), whereas later and slower pubertal timing and tempo were associated with decreases., Conclusions: In this urban South African cohort, relatively earlier and faster pubertal development was detrimental to mental health and risk behavior activity, whereas later and slower maturation was somewhat protective., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Father involvement in South Africa is low, despite evidence that it can improve maternal and child health and wellbeing. Within a larger randomised controlled trial, we assessed whether father involvement during and after pregnancy increased birth weight and exclusive breastfeeding through improved maternal mental health. At 6-week postnatal, mothers completed questionnaires on birth, feeding practices, social support, father involvement and postnatal depression. Father involvement during pregnancy was measured by their attendance at antenatal care and the study intervention, whereas postnatal involvement was measured by attendance at antenatal care and type of paternal support provided. Structural equation modelling was used to identify associations between father involvement, maternal depression, low birth weight and exclusive breastfeeding. Among the 212 mother-baby pairs, father involvement was very low with only 43%, 33% and 1% of partners attending early ultrasound, antenatal care and the birth of the child, respectively. Twenty-nine percent of the mothers showed signs of depression during pregnancy, compared with 7% after birth. Eighteen percent of the infants were born low birth weight, and 57% of mothers reported exclusively breastfeeding at 6 weeks. Father involvement was directly associated with postnatal depression, but it did not directly or indirectly impact exclusive breastfeeding or low birth weight. We conclude that postnatal father involvement can improve postnatal maternal depression and that men would benefit from specific guidance on how they can support mothers during and after pregnancy., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: The COVID-19 pandemic and containment measures have severely affected families around the world. It is frequently assumed that digital technologies can supplement and perhaps even replace services for families. This is challenging in conditions of high device and data costs as well as poor internet provision and access, raising concerns about widening inequalities in availability of support and consequent effects on child and family outcomes. Very few studies have examined these issues, including in low- and middle-income countries., Objective: The study objectives were two-fold. The first objective was to gather data on the impact of the COVID-19 pandemic on families of young children using an online survey. The second objective was to assess the feasibility of using a data-free online platform to conduct regular surveys and, potentially, to provide support for parents and families of young children in South Africa., Methods: We used a data-free mobile messenger platform to conduct a short digital survey of the impact of the COVID-19 pandemic on caring for young children in South Africa. We report on the methodological processes and preliminary findings of the online survey., Results: More than 44,000 individuals accessed the survey link and 16,217 consented to the short survey within 96 hours of its launch. Respondents were predominantly from lower classes and lower-middle classes, representing the majority of the population, with urban residential locations roughly proportionate to national patterns and some underrepresentation of rural households. Mothers comprised 70.2% (11,178/15,912) of respondents and fathers comprised 29.8% (4734/15,912), representing 18,672 children 5 years of age and younger. Response rates per survey item ranged from 74.8% (11,907/15,912) at the start of the survey to 50.3% (8007/15,912) at completion. A total of 82.0% (12,729/15,912) of parents experienced at least one challenge during the pandemic, and 32.4% (2737/8441) did not receive help when needed from listed sources. Aggregate and individual findings in the form of bar graphs were made available to participants to view and download once they had completed the survey. Participants were also able to download contact details for support and referral services at no data cost., Conclusions: Data-free survey methodology breaks new ground and demonstrates potential not previously considered. Reach is greater than achieved through phone surveys and some social media platforms, men are not usually included in parent surveys, costs are lower than phone surveys, and the technology allows for immediate feedback to respondents. These factors suggest that zero-rated, or no-cost, services could provide a feasible, sustainable, and equitable basis for ongoing interactions with families of young children., (©Linda Marleine Richter, Sara Naomi Naicker. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 28.06.2021.)

Background: Little is known about longitudinal patterns of adolescent health risk behavior initial engagement and persistence in low- and middle-income countries., Methods: Birth to Twenty Plus is a longitudinal birth cohort in Soweto-Johannesburg, South Africa. We used reports from Black African participants on cigarette smoking, alcohol, cannabis, illicit drug, and sexual activity initial engagement and adolescent pregnancy collected over 7 study visits between ages 11 and 18 y. We fit Kaplan-Meier curves to estimate behavior engagement or adolescent pregnancy, examined current behavior at age 18 y by age of first engagement, and performed a clustering analysis to identify patterns of initial engagement and their sociodemographic predictors., Results: By age 13 y, cumulative incidence of smoking and alcohol engagement were each > 21%, while the cumulative incidence of other behaviors and adolescent pregnancy were < 5%. By age 18 y (15 y for cannabis), smoking, alcohol, and sexual activity engagement estimates were each > 65%, cannabis and illicit drug engagement were each > 16%; adolescent pregnancy was 31%. Rates of engagement were higher among males. Current risk behavior activity at age 18 y was generally unrelated to age of initial engagement. We identified three clusters reflecting low, moderate, and high-risk patterns of initial risk behavior engagement. One-third of males and 17% of females were assigned to the high-risk cluster. Sociodemographic factors were not associated with cluster membership., Conclusions: Among urban dwelling Black South Africans, risk behavior engagement across adolescence was common and clustered into distinct patterns of initial engagement which were unrelated to the sociodemographic factors assessed. Patterns of initial risk behavior engagement may inform the timing of primary and secondary public health interventions and support integrated prevention efforts that consider multiple behaviors simultaneously.