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Background The quality of the home learning environment has a significant influence on children’s language and communication skills during the early years with children from disadvantaged families disproportionately affected. This paper describes the protocol and participant baseline characteristics of a community-based effectiveness study. It evaluates the effects of ‘smalltalk’, a brief group parenting intervention (with or without home coaching) on the quality of the early childhood home learning environment. Methods/design The study comprises two cluster randomised controlled superiority trials (one for infants and one for toddlers) designed and conducted in parallel. In 20 local government areas (LGAs) in Victoria, Australia, six locations (clusters) were randomised to one of three conditions: standard care (control); smalltalk group-only program; or smalltalk plus (group program plus home coaching). Programs were delivered to parents experiencing socioeconomic disadvantage through two existing age-based services, the maternal and child health service (infant program, ages 6–12 months), and facilitated playgroups (toddler program, ages 12–36 months). Outcomes were assessed by parent report and direct observation at baseline (0 weeks), post-intervention (12 weeks) and follow-up (32 weeks). Primary outcomes were parent verbal responsivity and home activities with child at 32 weeks. Secondary outcomes included parenting confidence, parent wellbeing and children’s communication, socio-emotional and general development skills. Analyses will use intention-to-treat random effects (“multilevel”) models to account for clustering. Recruitment and baseline data Across the 20 LGAs, 986 parents of infants and 1200 parents of toddlers enrolled and completed baseline measures. Eighty four percent of families demonstrated one or more of the targeted risk factors for poor child development (low income; receives government benefits; single, socially isolated or young parent; culturally or linguistically diverse background). Discussion This study will provide unique data on the effectiveness of a brief group parenting intervention for enhancing the early home learning environment of young children from disadvantaged families. It will also provide evidence of the extent to which additional one-on-one support is required to achieve change and whether there are greater benefits when delivered in the 1st year of life or later. The program has been designed for scale-up across existing early childhood services if proven effective. Trial registration 8 September 2011; ACTRN12611000965909.

International audience; Background: Women are more likely to have functional limitations than are men, partly because of greater socioeconomic disadvantage. However, how sex differences vary by severity of functional limitations remains unclear. We examined sex differences in functional limitations, with attention to socioeconomic factors and severity of limitations. Methods: Longitudinal data on limitations in basic activities of daily living (ADL) and instrumental activities of daily living (IADL) and mobility activities were drawn from 62 375 participants from 14 countries. For ADL, IADL, and mobility, participants were categorised based on number of limited activities (0, 1, 2, or ≥3). Sex differences in limitations in four birth cohorts (1895–1929, 1930–38, 1939–45, and 1946–60) were analysed before and after adjustment for socioeconomic factors (education and labour force status). Findings: The prevalence of IADL and ADL limitations was higher in women than in men. After adjustment for socioeconomic factors, this sex difference was attenuated. The sex difference in IADL limitations at age 75 years (in the 1895–1929 cohort) was 3·7% before adjustment for socioeconomic factors (95% CI 2·6–4·7) and 1·7% (1·1–2·2) after adjustment. For ADL, the sex difference in limitations at age 75 years (in the 1895–1929 cohort) was 3·2% (2·3–4·1) before adjustment for socioeconomic factors and 1·4% (0·9–1·8) after adjustment. Sex differences in mobility limitations (16·1%, 95% CI 14·4–17·7) remained after adjustment for socioeconomic factors (14·3%, 12·7–15·9). After age 85 years, women were more likely to have three or more IADL or mobility limitations and men were more likely to have one or two limitations. Interpretation: Socioeconomic factors largely explain sex differences in IADL and ADL limitations but not mobility. Sex differences in mobility limitations in midlife are important targets for future research and interventions. Funding: National Institute on Aging, UK National Institute for Health Research, European Commission, and US Social Security Administration

Objectives Factors common to socioeconomically disadvantaged neighborhoods, such as low availability of transportation, may limit access to restorative care services for critical illness survivors. Our primary objective was to evaluate whether neighborhood socioeconomic disadvantage was associated with an increased disability burden after critical illness. Our secondary objective was to determine if the effect differed for those discharged to the community compared with those discharged to a facility. Design Longitudinal cohort study with linked Medicare claims data. Setting United States. Patients One hundred ninety-nine older adults, contributing to 239 ICU admissions, who underwent monthly assessments of disability for 12 months following hospital discharge in 13 different functional tasks from 1998 to 2017. Measurements and main results Neighborhood disadvantage was assessed using the area deprivation index, a 1-100 ranking evaluating poverty, housing, and employment metrics. Those living in disadvantaged neighborhoods (top quartile of scores) were less likely to self-identify as non-Hispanic White compared with those in more advantaged neighborhoods. In adjusted models, older adults living in disadvantaged neighborhoods had a 9% higher disability burden over the 12 months following ICU discharge compared with those in more advantaged areas (rate ratio, 1.09; 95% Bayesian credible interval, 1.02-1.16). In the secondary analysis adjusting for discharge destination, neighborhood disadvantage was associated with a 14% increase in disability burden over 12 months of follow-up (rate ratio, 1.14; 95% credible interval, 1.07-1.21). Disability burden was 10% higher for those living in disadvantaged neighborhoods and discharged home as compared with those discharged to a facility, but this difference was not statistically significant (interaction rate ratio, 1.10; 95% credible interval, 0.98-1.25). Conclusions Neighborhood socioeconomic disadvantage is associated with a higher disability burden in the 12 months after a critical illness. Future studies should evaluate barriers to functional recovery for ICU survivors living in disadvantaged neighborhoods.

Major thermal burn injuries result in approximately 40,000 hospitalizations in the United States each year. Chronic pain affects up to 60% of burn survivors, and Black Americans have worse chronic pain outcomes than White Americans. Mechanisms of chronic pain pathogenesis after burn injury, and accounting for these racial differences, remain poorly understood. Due to socioeconomic disadvantage and differences in skin absorption, Black Americans have an increased prevalence of Vitamin D deficiency. We hypothesized that peritraumatic Vitamin D levels predict chronic pain outcomes after burn injury and contribute to racial differences in pain outcomes. Among burn survivors (n = 77, 52% White, 48% Black, 77% male), peritraumatic Vitamin D levels were more likely to be deficient in Blacks vs Whites (27/37 [73%] vs 14/40 [35%], P < .001). Peritraumatic Vitamin D levels were inversely associated with chronic post-burn pain outcomes across all burn injury survivors, including those who were and were not Vitamin D deficient, and accounted for approximately one-third of racial differences in post-burn pain outcome. Future studies are needed to evaluate potential mechanisms mediating the effect of Vitamin D on post-burn pain outcomes and the potential efficacy of Vitamin D in improving pain outcomes and reducing racial differences.

We investigate whether childhood exposures influence adult chronic inflammation and mortality risk via adult health characteristics and socioeconomic status (SES) and whether gender moderates these relationships. Analyzing a longitudinal national sample of 9,310 men and women over age 50, we found that childhood SES, parental behaviors, and adolescent behaviors were associated with adult chronic inflammation via health characteristics and SES in adulthood. The process of disadvantage initiated by low childhood SES (i.e., adult health risk factors, socioeconomic disadvantage, and chronic inflammation) subsequently raised mortality risk. In addition, gender moderated the mediating influence of childhood SES via unhealthy behaviors and parental behaviors via adult SES. Demonstrating how social forces shape biological health through multiple mechanisms informs health policies by identifying multiple points of intervention in an effort to reduce the lasting consequences of childhood disadvantage.

People who use illicit substances and experience socioeconomic disadvantage experience poor health as a result of structural vulnerabilities made worse by barriers to health care. In particular, st...

In recent years, several new medications for the treatment of type 2 diabetes have been released and some evidence indicates sociodemographic disparity in their utilisation. We sought to investigate sociodemographic disparities in receipt of diabetes medications across Australia. This study included 1,203,317 people with type 2 diabetes registered on the Australian National Diabetes Services Scheme (NDSS) followed from 2007 to 2015. The NDSS was linked to the Australian pharmaceutical claims database. We investigated trends in diabetes medication dispensing and variation in dispensing by sociodemographic strata. Compared with individuals in the least disadvantaged areas, those in the most disadvantaged quintile were less likely to receive dipeptidyl peptidase-4 inhibitors (DPP4is), glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium–glucose cotransporter 2 inhibitors (SGLT2is) in the first year of availability (OR [95% CI] for most vs least disadvantaged: 0.78 [0.75, 0.82], 0.65 [0.60, 0.71] and 0.89 [0.84, 0.95], respectively). These disparities dissipated over time for DPP4is and SGLT2is but remained significant for GLP-1RAs. The OR (95% CI) of receiving DPP4is, GLP-1RAs and SGLT2is in the first year of availability for people in remote areas vs major cities was 0.46 (0.39, 0.54), 0.46 (0.35, 0.61) and 0.71 (0.59, 0.84), respectively. These disparities remained significant through to 2015. People with diabetes in more disadvantaged areas are less likely to receive newer diabetes medications, although this effect decreased over time. However, there are considerable and persistent differences in receipt of newer diabetes medications between major cities and remote areas of Australia.

Objectives Children with celiac disease (CD) follow a lifelong gluten-free diet. This restrictive diet may be associated with nutritional compromise. Our objectives were, therefore, to evaluate the dietary composition (energy, macronutrients and micronutrients, and fiber) in children with CD compared with healthy controls (HC) and relationship between dietary composition and socioeconomic status. Methods This cross-sectional, case-control study recruited children with CD ages 2 to 18 years and HC matched for age, sex, and socioeconomic status. Clinical, sociodemographic, and dietary information were collected. A false discovery rate correction was applied to the P-value for multiple comparisons (q-value). Results Sixty-five CD children were matched with 65 HC (mean [SD] age: 10.2 [3.6] vs 10.1 [3.7] years, P = 0.96). Compared with HC, CD children had higher intakes of energy (2413.2 [489.9] vs 2190.8 (593.5) kcal/day, P = 0.02), total fat (818.1 ± 180.9 vs 714.3 ± 212.2 kcal/day, q = 0.018), and subtypes of fat (saturated, polyunsaturated, and monounsaturated). There were no differences in other macronutrients, sugar, micronutrients, or fiber between CD and HC, and no difference in dietary intake among CD between socioeconomic disadvantage versus advantage. Children with CD had lower weight z-scores (-0.06 [1.05] vs 0.47 [0.96], P = 0.003) and body mass index (BMI) z-scores (-0.02 [0.88] vs 0.41 [1.09], P = 0.02) than HC. Conclusions Children with CD had higher calorie and fat intake compared with HC. Despite this, CD children had lower weight and BMI z-scores compared with HC.

Background In Australia, a herpes zoster (HZ) vaccination program targeting adults aged 70 years old with catch-up for those 71-79 years began in November 2016 but there is limited information on vaccine uptake and coverage achieved since commencement. Methods We used a national de-identified electronic primary care dataset, MedicineInsight, and extracted records from patients turning 50–90 years old during 2016–2018. Among patients considered regular attenders, with at least one visit per year in the two years prior, we estimated the crude and adjusted average monthly HZ vaccine uptake in the target population (70–79 years old) for each year since program implementation as well as cumulative vaccine coverage until December 2018. Multivariate logistic regression was used to analyse characteristics associated with higher coverage. Results Among 52,229, 55,034, and 57,316 regular attenders turning 70–79 years old in 2016, 2017 and 2018 respectively, the average monthly vaccine uptake rate was 5.5%, 3.3%, and 1.6% respectively. Up to 31st December 2018, the estimated cumulative vaccine coverage in regularly attending adults was 46.9% (25,791/55,034). It was substantially lower at 41.6% (27,040/65,010) using an alternate definition of a regular attender. Vaccine coverage differed by sex (women: 48.5% versus men: 45.1%, adjusted OR = 1.1, 95% CI: 1.1–1.2); by jurisdiction (compared to New South Wales: 43.7%, South Australia: 55.6%, aOR = 1.6, 95% CI (1.5–1.8); Northern Territory: 27.6%, aOR = 0.6, (0.5–0.7)); by remoteness status (compared to major cities: 47.6%, remote/very remote areas: 38.2%, aOR = 0.7, (0.6–0.8)); and by socioeconomic disadvantage (compared to most disadvantaged: 41.8%, most advantaged: 48.6%, aOR = 1.6 (1.2–2.1)). Conclusions Our estimates of HZ vaccine coverage are substantially higher than the only other reports based on the Australian Immunisation Register however they still suggest that uptake is suboptimal. The use of electronic medical records can complement other data for estimating vaccine coverage in Australian adults.

The socioeconomic disadvantage may adversely affect HIV treatment outcomes, particularly in resource-limited settings. Data from people living with HIV (PLWH) who were receiving antiretroviral therapy (ART) in Guangxi, China were analyzed to investigate the impact of socioeconomic status (SES) on the immunologic outcome (i.e., CD4 counts). Among 1198 participants, 55.0% were having CD4 counts ≤500 cells/mm(3) and over two-third (68.5%) were considered to have a low level of SES. PLWH with high SES were more likely to have higher CD4 counts (adjusted Odds Ratio [aOR]: 1.44, 95%CI: 1.08–1.91) than PLWH with low SES, after adjusting for potential confounders. CD4 counts were also significantly associated with certain socio-demographic characteristics such as age, gender, and sexual orientation. In order to reduce SES-related disparity, a holistic approach may be needed to address the barriers to successful HIV treatment and care among PLWH with low SES. Poverty reduction and other structural interventions in addressing the socioeconomic disadvantages among PLWH should be key components of the national response to improving HIV treatment outcomes and ending the HIV epidemic in China and other low- and middle-income countries.

Background: Rectal cancer treatment outcomes for socioeconomically disadvantaged and regional patients have been suggested to be suboptimal in Australia. We investigate outcomes at a regional tertiary centre in order to determine the prognostic impact of patient and treatment factors. Methods: Patients who underwent short and long course neoadjuvant therapy followed by surgery for stage II–III rectal cancer over an 11‐year period were identified. Results were analysed to determine oncological and surgical outcomes along with whether patient and treatment‐related variables were prognostic. Accessibility/Remoteness Index of Australia (ARIA) and Index of Relative Socioeconomic Disadvantage (IRSD) was used to determine remoteness and socioeconomic status, respectively. Results: A total of 207 patients underwent short (n = 103, 49.8%) and long course (n = 104, 50.2%) over the time period; 81.6% (n = 169) were from outer regional, remote or very remote communities and 55.1% travelled >200 km for treatment; 57.0% were in the most disadvantaged three IRSD deciles. Five‐year cancer‐specific survival, recurrence‐free survival and local recurrence were 83.1% (n = 172), 76.3% (n = 158) and 7.3% (n = 15), respectively. Wound complications were higher in outer regional, remote or very remote patients (25.4% versus 13.2%, P = 0.03). Remoteness, socioeconomic indices, distance to treatment and neoadjuvant type were not prognostic for any other oncological or surgical outcomes on univariate or multivariate analysis. Conclusions: Despite demography suggesting geographic and socioeconomic barriers, oncological and surgical outcomes at our regional centre were comparable to international and Australian trials. Further, these factors were not prognostic. Geographically remote patient's may safely have neoadjuvant modality individualized without compromising care.

We provide a brief update on some aspects of chronic kidney disease (CKD) in Indigenous Australians, with CKD referring to all stages of pre-terminal kidney disease, as well as to end-stage kidney failure (ESKF), whether or not a person receives renal replacement therapy (RRT). Recently recorded rates of ESKF and RRT were 6- and 8-fold those recoded for non-Indigenous Australians with age adjustment, while non-dialysis CKD hospitalizations and CKD-attributed deaths were 8-fold and 3-fold higher. The median age of Indigenous people who developed ESKF was ~ 30 years less than for non-Indigenous people, and 84% of them received RTT, while only half of non-Indigenous people with ESKF did so. However, the nationwide average Indigenous incidence rate of RRT appears to have stabilized. The 2012 Australian Health Survey showed elevated levels of CKD markers in Indigenous people at the community level. For all CKD parameters, rates among Indigenous people were strikingly correlated with increasing remoteness of residence and socioeconomic disadvantage, and there was a female predominance in remote areas. The burden of renal disease in Australian Indigenous people is seriously understated by Global Burden of Disease Mortality methodology, because it employs underlying cause of death only, and because deaths of people on RRT are frequently attributed to non-renal causes. These data give a much-expanded view of CKD in Aboriginal people. Methodologic approaches must be remedied for a full appreciation of the burden, costs, and outcomes of the disease, to direct appropriate policy development. .

Childhood socioeconomic status (SES) is strongly predictive of math achievement in early childhood and beyond. In this study, we aimed to further our understanding of the mechanisms underpinning the SES-achievement gap by examining whether two aspects of self-regulation—executive functions (EF) and behavioral self-regulation (BSR)—mediate between SES and math achievement. Using data from a longitudinal study in Singapore (n = 1,257, 49% males), we examined the predictive link from SES to math achievement at entry to formal education (age 7), and the role of EF (child-assessed) and BSR (child-assessed and teacher-rated) as mediators of the SES-math achievement relationship. After accounting for children’s non-verbal reasoning and prior math achievement, EF and BSR (both child-assessed) emerged as significant partial mediators between SES and math. A key contribution of our study is in demonstrating that both components of self-regulation play a small role in explaining SES disparities in math achievement. Our findings further suggest that a balanced focus on enhancing EF and BSR skills of children from low-SES families may help to attenuate the SES-math achievement gap. More generally, our research contributes new insights to the ongoing debate about the theoretical distinctions between EF and BSR.

INTRODUCTION AND OBJECTIVE:Recent efforts to optimize recovery following radical cystectomy have not led to substantial improvement in complication rates. Though clinical risk factors have been rou...

BACKGROUND AND AIM: Living in a disadvantaged neighborhood has been linked to many adverse health outcomes. Chronic social and economic stressors associated with disadvantaged neighborhoods may als...

Aim The aim of this study was to describe sociodemographic and family predictors for behavioural and emotional problems in pre-schoolers. Methods This was a cross-sectional study including 30 795 children in the Stockholm region whose parents had completed the Strength and Difficulties Questionnaire (SDQ) prior to a routine visit to a well-baby clinic at age 3 years. Multivariate logistic regression was used to analyse predictors for having a high total SDQ difficulties score. Results Young parental age and a low level of parental education predicted high total SDQ score in a stepwise pattern. Being a first-born child was associated with a high SDQ score with an adjusted odds ratio of 2.10 (95% C.I. 1.84-2.41), compared with having older siblings. A sole physical custody arrangement predicted a high total SDQ score after parental separation. The percentage of children with a high total SDQ score increased with the Care Need Index (CNI) of the well-baby clinic. Conclusions This study identified socioeconomic disadvantage and being the first-born child as the main predictors of poor mental health at age 3 years. Well-baby clinics with socioeconomically disadvantaged catchment areas should be provided with adequate resources and methods for equitable prevention.

Background In the United States, hospitalizations for pulmonary embolism (PE) are increasing among older adults insured by Medicare. Although efforts to reduce health disparities have intensified, it remains unclear whether clinical outcomes differ between socioeconomically disadvantaged and nondisadvantaged Medicare beneficiaries hospitalized with PE. Methods and Results In this study, there were 53 386 Medicare fee‐for‐service beneficiaries age ≥65 years hospitalized for PE between October 2015 and January 2017. Of these, 5494 (10.3%) were socioeconomically disadvantaged and 47 892 (89.7%) were nondisadvantaged. Socioeconomically disadvantaged adults were of similar age as nondisadvantaged adults (77.1 versus 77.0), more likely to be female (68.5% versus 54.2%), and less likely to receive advanced therapies (11.0% versus 12.1%). After adjustment for demographics, 90‐day all‐cause mortality rates were similar between disadvantaged and nondisadvantaged adults. In contrast, 1‐year mortality rates were higher among socioeconomically disadvantaged adults (hazard ratio [HR], 1.16; 95% CI, 1.10–1.22), although these differences were partially attenuated after additional adjustments for comorbidities and PE severity (HR, 1.09; 95% CI, 1.02–1.16). Risk‐adjusted 30‐day and 90‐day all‐cause readmission rates were substantially higher among socioeconomically disadvantaged patients (30‐day HR, 1.14 [95% CI, 1.06–1.22]; 90‐day HR, 1.18 [95% CI, 1.12–1.25]). In addition, 90‐day readmissions attributed to PE, deep vein thrombosis, and/or bleeding were higher among socioeconomically disadvantaged patients (HR, 1.16; 95% CI, 1.02–1.32). Conclusions Socioeconomically disadvantaged older adults hospitalized with PE have higher 1‐year mortality rates compared with their nondisadvantaged counterparts. Nearly 1 in 3 socioeconomically disadvantaged older adults was readmitted within 90 days of a hospitalization for PE. Targeted strategies are needed to improve transitional and ambulatory care for this vulnerable population.

Background Very little is known about self-harm in children. We describe the characteristics and outcomes of children under 13 years who presented following self-harm to five hospitals in England. Methods We included children under 13 years who presented after self-harm to hospitals in the Multicentre Study of Self-harm in England. Information on patients’ characteristics and method of self-harm was available through monitoring of self-harm in the hospitals. Area level of socioeconomic deprivation was based on the English Index of Multiple Deprivation (IMD). Results 387 children aged 5–12 years presented to the study hospitals in 2000–2016, 39% of whom were 5–11 years. Boys outnumbered girls 2:1 at 5–10 years. The numbers of boys and girls were similar at age 11, while at 12 years there were 3.8 girls to every boy. The proportion of study children living in neighbourhoods ranked most deprived (43.4%) was twice the national average. 61.5% of children self-poisoned, 50.6% of them by ingesting analgesics. Of children who self-injured, 45.0% self-cut/stabbed, while 28.9% used hanging/asphyxiation. 32% of the children had a repeat hospital presentation for self-harm, 13.5% re-presented within a year. Conclusions Gender patterns of self-harm until age 11 years are different to those of adolescents, with a male preponderance, especially in 5–10 years, and hanging/suffocation being more common. The frequent use of self-poisoning in this age group highlights the need for public health messages to encourage safer household storage of medicines. Self-harm in children is strongly associated with socioeconomic deprivation; understanding the mechanisms involved could be important in effective prevention.

INTRODUCTION: Cigarette purchasing behavior may reflect quitting intentions. Little is known about how income could modify the association between cigarette purchasing behaviors and quit attempts among smokers experiencing homelessness. METHODS: Homeless, current smokers completed a questionnaire on the amount spent weekly on cigarettes (≤ $20/week versus > $20/week), source of cigarettes (store versus other source), quantity of cigarettes purchased (< pack versus ≥ pack), and past-year quit attempts. The association of participant income and these cigarette purchasing behaviors were examined. The relationship between cigarette purchasing behaviors and quit attempts was also examined and monthly income (none versus any) was explored as a potential moderator of this relationship. RESULTS: Of the 472 currently smoking individuals, 55% reported spending > $20/week on cigarettes, 83% reported purchasing cigarettes from a store, and 86% reported purchasing ≥ pack during their last purchase. Those who reported an income spent a third of their monthly income on cigarettes, and were more likely to spend > $20/week on cigarettes. The amount spent weekly on cigarettes and the source of cigarettes was not associated with quit attempts, nor did income moderate these relationships. Persons without an income who bought a pack or more of cigarettes made fewer quit attempts (β = −0.4, 95% CI −0.7, −0.2), whereas the association between quantity of cigarettes purchased and quit attempts was not significant for those with an income (β = −0.2, 95% CI −0.4, 0.1). CONCLUSIONS: Current smokers experiencing homelessness and who are without an income may find it particularly challenging to engage in attempts to quit smoking. Smoking cessation interventions that highlight relief of financial hardship as a potential benefit of successfully quitting smoking may be useful among this population.

There is now international consensus that building positive partnerships between home and school is critically important for children’s learning. However, the notion of family-school ‘partnership’ ...

Background Potentially preventable hospitalizations (PPHs) or ambulatory care sensitive conditions (ACSCs) represent hospitalizations that could be successfully managed in a primary care setting. Research from the USA and elsewhere on the role of primary care provider (PCP) access as a PPH driver has been conflicting. We investigated the role of PCP access in the creation of areas with persistently significant high rates of PPHs over time or PPH hotspots/spatial clusters. Methods Using a detailed dataset of PCPs and a dataset of 106 334 chronic PPH hospitalizations from South Western Sydney, Australia, we identified hotspots of chronic PPHs. We contrasted how hotspot PPHs were different from other PPHs on a range of factors including PCP access. Results and conclusions Six spatially contiguous areas comprising of eight postcodes were identified as hotspots with risks ranging from 1.6 to 2.9. The hotspots were found to be more disadvantaged and had better PCP access than other areas. Socioeconomic disadvantage explained the most variation (8%) in clustering while PCP access explained only a small fraction though using detailed PCP access measures helped. Nevertheless a large proportion of the variation remained unexplained (86.5%) underscoring the importance of individual level behaviours and other factors in driving chronic PPH clustering.

BACKGROUND AND OBJECTIVES A 2006-16 study investigated rheumatoid arthritis (RA) management by Australian general practitioners (GPs). The aim of this study was to examine: GP-patient encounters for RA management over the decade, treatments provided for RA management (new and continuing), characteristics of patients managed and of GPs providing management, and differences across regional areas and areas of socioeconomic advantage/disadvantage, compared with Australian guidelines. METHOD GP self-reported data collected through the Bettering the Evaluation And Care of Health (BEACH) program were analysed for patient and GP characteristics and management actions (medications, referrals, investigations, procedures) nationally, regionally and by socioeconomic advantage/disadvantage levels. RESULTS Proportions of RA management encounters: remained static across the decade, were higher for female patients, increased with patient and GP age, increased with socioeconomic disadvantage in major cities, were higher for patients from English-speaking backgrounds, and were higher in regional/remote areas. DISCUSSION GP behaviour indicates equity and uniformity in RA management nationally. The results suggest adherence to current guidelines for total and new RA contacts.

BackgroundDespite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.MethodsUsing data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.ResultsBeing female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).ConclusionsWe must continue to investigate how best to tailor psychotherapeutic interventions to fit patients’ needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.

Neighborhood greenness has been linked to better cardiovascular health, but little is known about its association with biomarkers related to cardiovascular risk. Adverse neighborhood conditions, such as disorder and socioeconomic disadvantage, are associated with higher cardiovascular biomarker levels, but these relationships may differ in neighborhoods with more greenness. This study evaluated cross-sectional associations of validated measures of neighborhood greenness, disorder, and socioeconomic disadvantage with cardiovascular biomarkers in middle-aged and older adults living in Baltimore City. The sample included 500 adults, aged 57–79 years, enrolled in the Baltimore Memory Study and living in Baltimore City during 2009–2010. Multi-level log-gamma regressions examined associations between the three neighborhood characteristics and seven cardiovascular biomarkers. Models additionally evaluated the effect modification by neighborhood greenness on associations of neighborhood disorder and socioeconomic disadvantage with the biomarkers. Adjusting for covariates and neighborhood greenness, greater neighborhood disorder was associated with higher C-reactive protein (exp β = 1.21, SE = 0.11, p = 0.035) and serum amyloid A (exp β = 1.28, SE = 0.12, p = 0.008), while greater neighborhood socioeconomic disadvantage was associated with higher tumor necrosis factor alpha (exp β = 1.24, SE = 0.12, p = 0.019). Higher neighborhood greenness was associated with lower soluble vascular cell adhesion molecule-1, accounting for disorder (exp β = 0.70, SE = 0.10, p = 0.010) and socioeconomic disadvantage (exp β = 0.73, SE = 0.10, p = 0.025). There was no evidence of effect modification among neighborhood characteristics. The findings suggest that neighborhood effects on cardiovascular health may be mediated through cardiovascular biomarker levels, and that socioeconomic disadvantage, disorder, and greenness may each be important features of neighborhoods. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11524-020-00499-7.

Introduction\ud The approach to thyroid hormone replacement varies across centres, but the extent and determinants of variation is unclear. We evaluated geographical variation in levothyroxine (LT4) and liothyronine (LT3) prescribing across General Practices in England and analysed the relationship of prescribing patterns to clinical and socioeconomic factors.\ud \ud Methods\ud Data was downloaded from the NHS monthly General Practice Prescribing Data in England for the period 2011-2020.\ud \ud Results\ud The study covered a population of 19.4 million women over 30 years of age, attending 6,660 GP practices and being provided with 33.7 million prescriptions of LT4 and LT3 at a total cost of £90million/year. Overall, 0.5% of levothyroxine treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019-2020. Factors strongly influencing more levothyroxine prescribing (model accounted for 62% of variance) were the CCG to which the practice belonged and the proportion of people with diabetes registered on the practice list plus antidepressant prescribing, with socioeconomic disadvantage associated with less levothyroxine prescribing. Whereas factors that were associated with increased levels of liothyronine prescribing (model accounted for 17% of variance), were antidepressant prescribing and % of type 2 diabetes mellitus individuals achieving HbA1c control of 58 mmol/mol or less. Factors that were associated with reduced levels of liothyronine prescribing included smoking and higher obesity rates.\ud \ud Conclusion\ud In spite of strenuous attempts to limit prescribing of liothyronine in general practice a significant number of patients continue to receive this therapy, although there is significant geographical variation in the prescribing of this as for levothyroxine, with specific general practice and CCG-related factors influencing prescribing of both levothyroxine and liothyronine across England.

Objective: To investigate the admission characteristics and hospital outcomes for patients admitted with lower respiratory tract infections (LRTI) in Northern Queensland. Methods: We perform a retrospective analysis of the data covering an 11‐year period, 2006–2016. Length of hospital stay (LOS) is modelled by negative binomial regression and heterogeneous effects are checked using interaction terms. Results: A total of 11,726 patients were admitted due to LRTI; 2,430 (20.9%) were of Indigenous descent. We found higher hospitalisations due to LRTI for Indigenous than non‐Indigenous patients, with a disproportionate increase in hospitalisations occurring during winter. The LOS for Indigenous patients was higher by 2.5 days [95%CI: ‐0.15; 5.05] than for non‐Indigenous patients. The average marginal effect of 17.5 [95%CI: 15.3; 29.7] implies that the LOS for a patient, who was admitted to ICU, was higher by 17.5 days. Conclusions: We highlighted the increased burden of LRTIs experienced by Indigenous populations, with this information potentially being useful for enhancing community‐level policy making. Implications for public health: Future guidelines can use these results to make recommendations for preventative measures in Indigenous communities. Improvements in engagement and partnership with Indigenous communities and consumers can help increase healthcare uptake and reduce the burden of respiratory diseases.

Introduction: Living in a disadvantaged neighborhood is associated with developing cardiovascular disease and poor health outcomes. We hypothesized that socioeconomic disadvantage - as measured by neighborhood level factors - is associated with cardiovascular (CV) mortality for patients who experienced a myocardial infarction (MI) at a young age. Methods: Retrospective cohort study of patients with a first MI at age Results: Of 2097 patients (median age 44; 19% female), addresses were available for 96%. The median NSS score was -0.31, with scores ranging from -1.11 to 5.33. Higher NSS scores were associated with public insurance, hypertension, diabetes, smoking cigarettes, and illicit drug use. Over a median follow-up of 11 years, 12.7% of individuals in the top tertile died versus 7.5% in the bottom tertile, p=0.002. After adjusting for age, sex, race, diabetes, hypertension, dyslipidemia, creatinine, tobacco smoking, use of alcohol or illicit drugs, cardiac catheterization, and statin or aspirin at discharge, each 1-point increase in NSS was associated with a 25% increase in CV mortality (adjusted HR = 1.25, [95% CI 1.01 - 1.55], p=0.045). Conclusion: Among patients experiencing an MI at a young age, socioeconomic disadvantage was associated with higher CV mortality. Our data suggest that neighborhood factors have an important effect on post-MI survival.

Compared to others, individuals living in communities of socioeconomic disadvantage experience more atherosclerotic cardiovascular disease (CVD) and a greater extent of preclinical atherosclerosis. Although the mechanisms underlying these associations remain unclear, it is widely hypothesized that alterations in normative cortisol release from the Hypothalamic Pituitary Adrenal (HPA) axis may play a role in linking lower community socioeconomic position (C-SEP) to CVD risk. The current study examined this hypothesis in relation to a marker of preclinical atherosclerosis among 488 healthy midlife adults (30–54 years, Mean age= 43, 52% Female, 81% White). All participants were employed and without clinical CVD. C-SEP was estimated from census tract data, and atherosclerosis was measured as intima-medial thickness of the carotid arteries (cIMT) by duplex ultrasonography. Four indicators of HPA activity [cortisol at awakening and the cortisol awakening response (CAR), rate of diurnal decline in cortisol (diurnal slope), and total output expressed as area under the curve (AUC)] were derived from salivary cortisol measurements obtained from 5 samples on each of 3 working days. Path analyses were used to examine associations of C-SEP with cIMT and HPA activity and to test whether individual differences in HPA activity could account for any association of C-SEP with cIMT using bootstrapping (5000 iterations). All models were adjusted for age, sex, race, and composite measures of both individual-level socioeconomic position (income, education, occupation), and cardiometabolic risk (systolic and diastolic blood pressure, waist circumference, fasting lipids and glucose). Lower C-SEP was related to both greater cIMT (b = −0.004, p = .021) and a flatter diurnal slope of cortisol (b = −0.001, p = .039). An indirect effect showed attenuated diurnal slope to partially mediate the relationship between C-SEP and cIMT (95% CI = −0.0018 to −0.0001), and a residual direct effect of C-SEP on cIMT remained significant (95% CI = −0.0097 to −0.004). These results suggest that low C-SEP associations with preclinical atherosclerosis may be due in part to correlated variation in adrenocortical activity.

Background Clostridioides difficile infection (CDI) is commonly associated with outcomes like recurrence and readmission. The effect of social determinants of health, such as ‘neighborhood’ socioeconomic disadvantage, on a CDI patient’s health outcomes is unclear. Living in a disadvantaged neighborhood could interfere with a CDI patient’s ability to follow post-discharge care recommendations and the success probability of these recommendations, thereby increasing risk of readmission. We hypothesized that neighborhood disadvantage was associated with 30-day readmission risk in Medicare patients with CDI. Methods In this retrospective cohort study, odds of 30-day readmission for CDI patients are evaluated controlling for patient sociodemographics, comorbidities, and hospital and stay-level variables. The cohort was created from a random 20% national sample of Medicare patients during the first 11 months of 2014. Results From the cohort of 19,490 patients (39% male; 80% white; 83% 65 years or older), 22% were readmitted within 30 days of an index stay. Unadjusted analyses showed that patients from the most disadvantaged neighborhoods were readmitted at a higher rate than those from less disadvantaged neighborhoods (26% vs. 21% rate: unadjusted OR = 1.32 [1.20, 1.45]). This relationship held in adjusted analyses, in which residence in the most disadvantaged neighborhoods was associated with 16% increased odds of readmission (adjusted OR = 1.16 [1.04, 1.28]). Conclusions Residence in disadvantaged neighborhoods poses a significantly increased risk of readmission in CDI patients. Further research should focus on in-depth assessments of this population to better understand the mechanisms underlying these risks and if these findings apply to other infectious diseases.

Background: Patients with serious mental illness (SMI) are vulnerable to medical-surgical readmissions and emergency department visits. Community socioeconomic disadvantage has been associated with readmission risk in the general population, but its impact on other types of revisits (emergency department visits and observation stays), particularly in patients with SMI, is unknown. Methods: We used Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project discharge abstracts for 1,914,619 patients with SMI discharged after medical-surgical admissions in Florida and New York between 2012 and 2015 and their revisits to the hospital within 30 days of discharge. We linked this data to the Area Deprivation Index for the communities that patients returned to.Results: Patients with SMI returning to the most disadvantaged communities had greater adjusted 30-day revisit rates than patients from less disadvantaged communities. Among those that experienced a revisit, patients returning the most disadvantaged communities had 7.3% greater 30-day observation stay revisits. Conclusion: These results suggest that additional investments are needed to ensure that patients with SMI returning the most socioeconomically disadvantaged communities are receiving appropriate post-discharge care.

BACKGROUND: Disparities in THA use may lead to inequitable care. Prior research has focused on disparities based on individual-level and isolated socioeconomic and demographic variables. To our knowledge, the role of composite, community-level geographic socioeconomic disadvantage has not been studied in the United States. As disparities persist, exploring the potential underlying drivers of these inequities may help in developing more targeted recommendations on how to achieve equitable THA use. QUESTIONS/PURPOSES: (1) Is geographic socioeconomic disadvantage associated with decreased THA rates in Medicare-aged patients? (2) Do these associations persist after adjusting for differences in gender, race, ethnicity, and proximity to hospitals performing THA? METHODS: In a study with a cross-sectional design, using population-based data from five-digit ZIP codes in Maryland, USA, from July 1, 2012 to March 31, 2019, we included all inpatient and outpatient primary THAs performed in individuals 65 years of age or older at acute-care hospitals in Maryland, as reported in the Health Services Cost Review Commission database. This database was selected because it provided the five-digit ZIP code data necessary to answer our study question. We excluded THAs performed for nonelective indications. We examined the annual rate of THA in our study population for each Maryland ZIP code, adjusted for differences across areas in distributions of gender, race, ethnicity, and distance to the nearest hospital performing THAs. Four hundred fourteen ZIP codes were included, with an overall mean ± SD THA rate of 371 ± 243 per 100,000 persons 65 years or older, a rate similar to that previously reported in individuals aged 65 to 84 in the United States. Statistical significance was assessed at α = 0.05. RESULTS: THA rates were higher in more affluent areas, with the following mean rates per 100,000 persons 65 years or older: 422 ± 259 in the least socioeconomically disadvantaged quartile, 339 ± 223 in the second-least disadvantaged, 277 ± 179 in the second-most disadvantaged, and 214 ± 179 in the most-disadvantaged quartile (p < 0.001). After adjustment for distributions in gender, race, ethnicity, and hospital proximity, we found that geographic socioeconomic disadvantage was still associated with THA rate. Compared with the least-disadvantaged quartile, the second-least disadvantaged quartile had 63 fewer THAs per 100,000 people (95% confidence interval 12 to 114), the second-most disadvantaged quartile had 136 fewer THAs (95% CI 62 to 211), and the most-disadvantaged quartile had 183 fewer THAs (95% CI 41 to 325). CONCLUSION: Geographic socioeconomic disadvantage may be the underlying driver of disparities in THA use. Although our study does not determine the “correct” rate of THA, our findings support increasing access to elective orthopaedic surgery in disadvantaged geographic communities, compared with prior research and efforts that have studied and intervened on the basis of isolated factors such as race and gender. Increasing access to orthopaedic surgeons in disadvantaged neighborhoods, educating physicians about when surgical referral is appropriate, and educating patients from these geographic communities about the risks and benefits of THA may improve equitable orthopaedic care across neighborhoods. Future studies should explore disparities in rates of appropriate THA and the role of density of orthopaedic surgeons in an area. LEVEL OF EVIDENCE: Level III, therapeutic study.

Objective: To compare disease presentation and outcome in Aboriginal and non-Aboriginal children with acute leukaemia and to assess the impact of remoteness and area-based socioeconomic disadvantage. Design: A retrospective review of children treated for acute leukaemia from South Australia (SA), Northern Territory (NT) and Western Australia (WA) between 2009 and 2018. Setting: Women’s and Children’s Hospital (WCH), Adelaide and Perth Children’s Hospital (PCH) - the sole referral sites for paediatric cancer for SA, NT and WA. Participants: Eligible patients, aged between 1 day and

Background Persons with low socioeconomic status may be disproportionately at risk for multimorbidity. Methods Adults aged ≥20 years on 4/1/2015 from 7 counties in Minnesota were identified using the Rochester Epidemiology Project (population-based sample). A composite measure of neighborhood socioeconomic disadvantage, the area deprivation index (ADI), was estimated at the census block group level (n = 251). The prevalence of 21 chronic conditions was obtained to calculate the proportion of persons with multimorbidity (≥2 chronic conditions) and severe multimorbidity (≥5 chronic conditions). Hierarchical logistic regression was used to estimate the association of ADI with multimorbidity and severe multimorbidity using odds ratios (OR). Results Among 198,941 persons (46.7% male, 30.6% aged ≥60 years), the age- and sex-standardized (to the United States 2010 census) median prevalence (Q1, Q3) was 23.4% (21.3%, 25.9%) for multimorbidity and 4.8% (4.0%, 5.7%) for severe multimorbidity. Compared with persons in the lowest quintile of ADI, persons in the highest quintile had a 50% increased risk of multimorbidity (OR 1.50, 95% CI 1.39–1.62) and a 67% increased risk of severe multimorbidity (OR 1.67, 95% CI 1.51–1.86) after adjusting for age, sex, race, and ethnicity. Associations were stronger after further adjustment for individual level of education; persons in the highest quintile had a 78% increased risk of multimorbidity (OR 1.78, 95% CI 1.62–1.96) and a 92% increased risk of severe multimorbidity (OR 1.92, 95% CI 1.72–2.13). There was evidence of interactions between ADI and age, between ADI and sex, and between ADI and education. After age 70 years, no difference in the risk of multimorbidity was observed across quintiles of ADI. The pattern of increasing multimorbidity with increasing ADI was more pronounced in women. Finally, there was less variability across quintiles of ADI for the most highly educated group. Conclusions Higher ADI was associated with increased risk of multimorbidity, and the associations were strengthened after adjustment for individual level of education, suggesting that neighborhood context plays a role in health above and beyond individual measures of socioeconomic status. Furthermore, associations were more pronounced in younger persons and women, highlighting the importance of interventions to prevent chronic conditions in younger women, in particular.

Most households with a smoker do not implement comprehensive smoke-free rules (smoke-free homes and cars), and secondhand smoke (SHS) exposure remains prevalent among children and low-socioeconomic status (SES) populations. This pilot project aimed to assess implementation feasibility and impact of an intervention designed to increase smoke-free rules among socioeconomically disadvantaged households with children. The pilot was implemented through Minnesota&rsquo, s National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDPs provide cancer prevention services to low-income individuals experiencing health disparities. We successfully utilized and adapted the Smoke-Free Homes Program (SFHP) to address comprehensive smoke-free rules among households with children. We used two recruitment methods: (a) direct mail (DM) and (b) opportunistic referral (OR) by patient navigators in the NBCCEDP call center. We used descriptive statistics to assess implementation outcomes and hierarchical logistic regression models (HLM) to assess change in smoke-free rules and SHS exposure over the study period. There was no comparison group, and HLM was used to examine within-person change. A total of 64 participants were recruited. Results showed 83% of participants were recruited through DM. OR had a high recruitment rate, and DM recruited more participants with a low response rate but higher retention rate. Among recruited participants with data (n = 47), smoke-free home rules increased by 50.4 percentage points during the study period (p &lt, 0.001). Among recruited participants who had a vehicle (n = 38), smoke-free car rules increased by 37.6 percentage points (p &lt, 0.01) and comprehensive smoke-free rules rose 40.9 percentage points (p &lt, 0.01). Home SHS exposure declined, and within-person increase in smoke-free home rules was significantly related to less home SHS exposure (p &lt, 0.05). It is feasible to adapt and implement the evidence-based SFHP intervention through a national cancer program, but the current pilot demonstrated recruitment is a challenge. DM produced a low response rate and therefore OR is the recommended recruitment route. Despite low recruitment rates, we conclude that the SFHP can successfully increase comprehensive smoke-free rules and reduce SHS exposure among socioeconomically disadvantaged households with children recruited through a NBCCEDP.

Background Childhood adversity has been previously associated with alterations in brain structure, but heterogeneous designs, methods, and measures have contributed to mixed results and have impeded progress in mapping the biological embedding of childhood adversity. We sought to identify long-term differences in structural brain integrity associated with childhood adversity. Methods Multiple regression was used to test associations between prospectively ascertained adversity during childhood and adversity retrospectively reported in adulthood with structural magnetic resonance imaging measures of midlife global and regional cortical thickness, cortical surface area, and subcortical gray matter volume in 861 (425 female) members of the Dunedin Study, a longitudinal investigation of a population-representative birth cohort. Results Both prospectively ascertained childhood adversity and retrospectively reported adversity were associated with alterations in midlife structural brain integrity, but associations with prospectively ascertained childhood adversity were consistently stronger and more widely distributed than associations with retrospectively reported childhood adversity. Sensitivity analyses revealed that these associations were not driven by any particular adversity or category of adversity (i.e., threat or deprivation) or by childhood socioeconomic disadvantage. Network enrichment analyses revealed that these associations were not localized but were broadly distributed along a hierarchical cortical gradient of information processing. Conclusions Exposure to childhood adversity broadly is associated with widespread differences in midlife gray matter across cortical and subcortical structures, suggesting that biological embedding of childhood adversity in the brain is long lasting, but not localized. Research using retrospectively reported adversity likely underestimates the magnitude of these associations. These findings may inform future research investigating mechanisms through which adversity becomes embedded in the brain and influences mental health and cognition.

Children growing up in families experiencing socioeconomic disadvantage (SED) are at greater risk for deficits in attachment and stress regulation as compared to peers in families with more socioeconomic resources. The present study hypothesized that care providers in out-of-home care might help these children to compensate. We therefore investigated 60 children (n = 30 from SED, n = 30 matched counterparts from middle class) and assessed children's Attachment Q-Sort (AQS) toward the mother and the primary care provider in childcare centers. Moreover, children's diurnal cortisol rhythm was measured based on 12 saliva samples taken across three days a week. The disadvantaged children showed lower AQS scores with their mothers than their care providers. Compared to their counterparts, disadvantaged children also displayed heightened cortisol release and flatter cortisol profiles reflecting overall high hypothalamic-pituitary-adrenocortical activities and lower capacities to regulate stress. Most notably however, multilevel path modeling linked higher care provider AQS scores to decreasing cortisol release throughout the week.Los niños que crecen en familias que experimentan desventajas socioeconómicas (SED) se encuentran bajo mayor riesgo de déficits en la afectividad y regulación del estrés, comparados con compañeros de familias con más recursos socioeconómicos. EL presente estudio presenta la hipótesis de que quienes cuidan a estos niños dentro del sistema público de guarderías pudieran ayudarles a compensar. Nosotros, por tanto, investigamos a 60 niños (n = 30 de SED, n = 30 niños de clase media pareados como contraparte) y evaluamos la afectividad de los niños (AQS) hacia las madres y quienes les proveían el cuidado primario en guarderías infantiles públicas. Es más, se midió el ritmo diurno de cortisol de los niños con base en 12 muestras de saliva tomadas a lo largo de tres días a la semana. Los niños con desventajas mostraron más bajos puntajes de AQS con sus madres que con quienes les prestaban el cuidado. Comparados con su contraparte, los niños con desventajas también mostraron un elevado nivel de emisión de cortisol y perfiles de cortisol más planos lo cual refleja en general un alto nivel de actividades HPA y más bajas capacidades para regular el estrés. Aún más notable, sin embargo, el modelo de trayectoria a múltiples niveles relacionó los más altos puntajes AQS del cuidador con una baja en la emisión de cortisol a lo largo de la semana.Les enfants grandissant dans des familles faisant l'expérience d'un désavantage socioéconomique (abrégé ici DSE) sont à plus grand risque de déficits dans l'attachement et la régulation du stress comparés aux enfants grandissant dans des familles dotées de plus de ressources socioéconomiques. Cette étude a pris pour hypothèse que les personnes s'occupant des enfants dans les crèches publiques pourraient aider ces enfants à compenser. Nous avons donc étudié 60 enfants (n = 30 de SED, n = 30 homologues issus de la classe moyenne) et évalué l'attachement (AQS) des enfants envers leur mère et envers les personnes prenant soin d'eux dans les crèches publiques. De plus le rythme de cortisol diurne a été mesuré basé sur des échantillons de salive pris au cours de trois jours par semaine. Les enfants de milieu désavantagé ont fait preuve de scores AQS plus bas avec leurs mères qu'avec les personnes prenant soin d'eux dans les crèches. Comparés à leurs homologues, les enfants désavantagés ont aussi fait preuve de sécrétion de cortisol plus élevée et des profils de cortisol plus plats reflétaient des activités HPA dans l'ensemble hautes et des capacités plus basses à réguler le stress. Plus particulièrement cependant une modélisation à plusieurs niveaux a établi un lien entre des scores AQS plus élevés des modes de soin à la crèche à des sécrétions de cortisol décroissantes tout au long de la semaine.Bindung und Stressregulierung bei sozioökonomisch benachteiligten Kindern: Kann die öffentliche Kinderbetreuung kompensieren? Kinder aus Familien, die sozioökonomisch benachteiligten sind (socioeconomic disadvantage; SED), haben im Vergleich zu Gleichaltrigen aus Familien mit mehr sozioökonomischen Ressourcen ein höheres Risiko für Defizite bezüglich Bindung und Stressregulierung. Die Hypothese der vorliegenden Studie ist, dass Erzieher_innen in der öffentlichen Kinderbetreuung diesen Kindern helfen können, dies zu kompensieren. Wir untersuchten 60 Kinder (n = 30 aus SED Familien, n = 30 gleichaltrige Kontrollproband_innen aus der Mittelklasse) und beurteilten deren Bindung zur Mutter sowie zur primären Bezugsperson in der öffentlichen Kindertagesstätte (AQS). Darüber hinaus wurde der tägliche Cortisolrhythmus der Kinder anhand von 12 Speichelproben gemessen, die an drei Tagen in der Woche entnommen wurden. Die sozioökonomisch benachteiligten Kinder erzielten bei ihren Müttern niedrigere AQS-Werte als bei ihren Erzieher_innen. Im Vergleich zur Kontrollgruppe wiesen die sozioökonomisch benachteiligten Kinder auch eine erhöhte Cortisolfreisetzung und flachere Cortisolprofile auf, was auf insgesamt hohe HPA-Aktivitäten und geringere Kapazitäten zur Stressregulierung zurückgeführt werden kann. Insbesondere aber zeigte sich durch eine Multilevel-Pfadmodellierung ein Zusammenhang zwischen höheren AQS-Werten bei den Erzieher_innen und geringerer wöchentlicher Cortisolfreisetzung.社会経済的に貧しい子どもたちのアタッチメントとストレス制御 abstract: 抄録 社会経済的に貧しい(SED)家族のもとで育っている子どもたちは、社会経済的な 資源のある家族のもので育っている子どもたちに比べ、アタッチメントとストレ ス制御に関して欠損しているリスクが高い。本研究では、公の保育現場の保育者 らがこのこどもたちを支援し、それを補償するのではないかと仮定した。そのた め、60人の子ども(SED:n = 30 、中産階級の同等の子ども:n = 30)を調査し、 母親と公の保育園の主な保育者に対する子どもの(AQS)アタッチメントについて 評価した。さらに、子どもの日中のコルチゾールリズムを週3日にわたり、12の 唾液サンプルを採取し、測定した。 社会経済的に貧しい子どもたちは、保育者より母親に対してより低いAQS値を示 した。中産階級の子どもたちと比較して、社会経済的に貧しい子どもたちはまた、 全体的に高いHPA活動とストレスを制御するための低能力を反映して、高いコル チゾール放出とより横ばいのコルチゾールプロファイルを示していた。しかし、 特に重要なことは、多層経路モデルが、週を通じてより高い保育者のAQS値がコ ルチゾール放出を減少させることに関係している事であった。.摘 要:与拥有更多社会经济资源的家庭中的同龄儿童相比, 处于社会经济劣势(SED)的家庭中长大的儿童, 在依恋和压力调节方面存在缺陷的风险更大。本研究假设公共看护机构的看护者们可能会帮助这些儿童弥补这方面的缺陷。基于此, 我们调查了60名儿童 (来自SED的儿童n = 30, 来自中产阶级的相匹配的同龄儿童n = 30) , 并评估 (AQS) 了每位儿童对他们的母亲以及公共看护机构中最初那位看护者的依恋程度。此外, 我们还根据每周中三天采集的12份唾液样本来测量这些儿童的皮质醇昼夜节律。结果显示, 社会经济劣势的儿童与其母亲的AQS得分低于他们与看护者们的得分。与其他相匹配的同龄儿童相比, 这些儿童的皮质醇释放量更高, 皮质醇分布曲线更平坦, 这反映出整体较高的HPA活动和较低的压力调节能力。但是, 值得注意的是, 多层次路径模型显示出, 在儿童与看护者AQS得分较高的整个星期中, 皮质醇释放量却在逐步下降。.التعلق وتنظيم الإجهاد عند الأطفال المحرومين اجتماعيا ً واقتصادياً: هل تقدم رعاية الأطفال العامة التعويض المطلوب؟ ملخص الأطفال الذين ينشأون في أسر تعاني من الحرمان الاجتماعي والاقتصادي (SED) هم أكثر عرضة للعجز في التعلق وتنظيم الإجهاد مقارنة بأقرانهم في الأسر ذات الموارد الاجتماعية والاقتصادية الأكثر. افترضت هذه الدراسة أن مقدمي الرعاية في الرعاية العامة للأطفال قد يساعدون هؤلاء الأطفال على التعويض. ولذلك قمنا بالتحقيق مع 60 طفلاً (30 طفل من الفئات المحرومة اجتماعيا واقتصاديا و30 طفل من الطبقة المتوسطة) وقيمنا تعلق الأطفال(AQS) بالأم ومقدم الرعاية الأولية في مراكز رعاية الطفل العامة. وعلاوة على ذلك، تم قياس إيقاع الكورتيزول اليومي للأطفال على أساس 12 عينة من اللعاب تؤخذ عبر ثلاثة أيام في الأسبوع. وأظهر الأطفال المحرومون درجات أقل على مقياسAQS مع أمهاتهم مقارنة بمقدمي الرعاية. بالمقارنة مع نظرائهم، أظهر الأطفال المحرومون أيضًا إفراز كورتيزول متزايد وملامح الكورتيزول التملقية التي تعكس أنشطةHPA العالية بشكل عام وقدرات أقل لتنظيم الإجهاد. وأبرزها ومع ذلك، ربط نمذجة المسار متعدد المستويات أعلى مستوى الرعايةAQS عشرات لخفض الإفراج الكورتيزول على مدار الأسبوع.

Objectives To examine whether increased socioeconomic disadvantage, indexed using a measure of community distress, was associated with variation in caregiver-reported early childhood sleep patterns and problems in a large US sample using a mobile health application (app). Design Cross-sectional. Setting Data were collected using the free, publicly available Johnson's Bedtime© baby sleep app. Participants A total of 14,980 caregivers (85.1% mothers) of children ages 6-35.9 months (M = 13.88 months; 52.6% boys) participated in this study. Measures Caregivers reported on child sleep using the Brief Infant Sleep Questionnaire-Revised. Socioeconomic disadvantage was indexed by zip code using the Distressed Communities Index (DCI), which combines seven US census indicators of socioeconomic disadvantage. DCI scores range from prosperous (lowest quintile) to distressed (highest quintile). Results Socioeconomic disadvantage was significantly associated with later bedtimes, longer sleep onset latency, and shorter nighttime and 24-hour (total) sleep duration, with children living in distressed communities showing the poorest sleep. However, caregivers living in distressed communities reported a significantly lower prevalence of overall child sleep problems (43% vs 58% in prosperous communities), and more confidence in managing child sleep (42% vs 34% in prosperous communities). Conclusions Children living in the most distressed communities have the poorest reported sleep patterns and bedtime behaviors; however, their caregivers are less likely to report problematic child sleep. These findings highlight the need for community-level sleep health promotion interventions, as well as further investigation of caregiver perceptions about child sleep and sleep health promotion among families living in socioeconomically disadvantaged contexts.

Background Effective strategies for participant retention are critical in health research to ensure validity, generalizability and efficient use of resources. Yet standardized guidelines for planning and reporting on retention efforts have been lacking. As with randomized controlled trial (RCT) and systematic review (SR) protocols, retention protocols are an opportunity to improve transparency and rigor. An RCT being conducted in British Columbia (BC), Canada provides a case example for developing a priori retention frameworks for use in protocol planning and reporting. Methods The BC Healthy Connections Project RCT is examining the effectiveness of a nurse home-visiting program in improving child and maternal outcomes compared with existing services. Participants (N = 739) were girls and young women preparing to parent for the first time and experiencing socioeconomic disadvantage. Quantitative data were collected upon trial entry during pregnancy and during five follow-up interviews until participants’ children reached age 2 years. A framework was developed to guide retention of this study population throughout the RCT. We reviewed relevant literature and mapped essential retention activities across the study planning, recruitment and maintenance phases. Interview completion rates were tracked. Results Results from 3302 follow-up interviews (in-person/telephone) conducted over 4 years indicate high completion rates: 90% (n = 667) at 34 weeks gestation; and 91% (n = 676), 85% (n = 626), 80% (n = 594) and 83% (n = 613) at 2, 10, 18 and 24 months postpartum, respectively. Almost all participants (99%, n = 732) provided ongoing consent to access administrative health data. These results provide preliminary data on the success of the framework. Conclusions Our retention results are encouraging given that participants were experiencing considerable socioeconomic disadvantage. Standardized retention planning and reporting may therefore be feasible for health research in general, using the framework we have developed. Use of standardized retention protocols should be encouraged in research to promote consistency across diverse studies, as now happens with RCT and SR protocols. Beyond this, successful retention approaches may help inform health policy-makers and practitioners who also need to better reach, engage and retain underserved populations. Trial registration ClinicalTrials.gov, NCT01672060. Registered on 24 August 2012.

Canine parvovirus (CPV) is a cause of severe disease in dogs globally, yet is preventable by vaccination. A range of vaccination protocols are used by veterinary practitioners with evidence suggesting some protocols provide better protection than others in high infection-risk situations. This study investigated associations between veterinarians' vaccination recommendations and hospital remoteness, socioeconomic disadvantage, CPV caseload, and veterinarian perceptions and demographics. A national Australian veterinary survey in 2017 received 569 practitioner responses from 534 unique hospitals (23.6 % response rate). Respondents from major city hospitals had the lowest perceptions of the national CPV caseload (p0.0001). Those from hospitals with mild to moderate caseloads (6-40 cases per annum) recommended more frequent puppy revaccination - which is considered more protective - than those with the highest caseload (p = 0.0098), which might increase vaccination failure risk. Respondents from the most socioeconomically disadvantaged regions were over-represented in recommending annual revaccination of adult dogs; those from the least disadvantaged regions were over-represented in recommending triennial revaccination (p0.0001). Hospitals with higher CPV caseloads, greater socioeconomic disadvantage or increased remoteness did not favor two puppy vaccination protocols that are considered more protective (younger first vaccination age or older final vaccination age), despite these regions presenting higher CPV caseload risk. Titer testing to determine whether to revaccinate was more likely to be used in major city hospitals (p = 0.0052) and less disadvantaged areas (p = 0.0550). University of graduation was associated with CPV caseload, remoteness and level of socioeconomic disadvantage of the region where the graduate worked. University of graduation was significantly associated with age for final puppy vaccination and titer-testing recommendations. Graduates from one university were over-represented in recommending an earlier (10-week) finish protocol and titer testing, compared to all other universities. Year and university of graduation, and respondent's age were associated with a number of vaccination protocol recommendations suggesting that inherent biases might affect veterinarians' decisions. Emphasis on currently recommended vaccination protocols in undergraduate curricula and more protective vaccination protocol use in higher-risk regions could reduce immunization failure and CPV caseload.

We examined whether elucidating underpinning smoking motivation and related pharmacological processes enhances understanding of nicotine dependence among smokers from vulnerable populations. Data were obtained between Oct, 2016 and Sept, 2019 from 745 adult smokers with co-morbid psychiatric conditions or socioeconomic disadvantage at University of Vermont, Brown University, Johns Hopkins University. Smoking motivation was assessed using the Cigarette Purchase Task (CPT), a behavioral-economic task that models the relative reinforcing value of smoking under varying monetary constraint. Dependence severity was measured using the Heaviness of Smoking Index (HSI), Fagerstrom Test for Nicotine Dependence total scores (FTND), and FTND total scores minus items 1 and 4 (FTND2,3,5,6). We also assessed associations between dependence severity and smoking motivation with nicotine levels and metabolism rate. Principal Component Analysis was used to examine the latent structure of the conventional five CPT indices; bivariate and multivariable modeling was used to test associations. Factor analysis resulted in a two-factor solution, Amplitude (demand unconstrained by price) and Persistence (price sensitivity). CPT latent factors were associated with each dependence-severity measure (ps ≤ 0.0001), with associations stronger for Amplitude than Persistence across each, especially HSI which was exclusively associated with Amplitude. Amplitude and each dependence measure were associated with nicotine intake (ps ≤ 0.0002); Persistence was not (p = .19). Demand Amplitude more than Persistence appears key to understanding individual differences in dependence severity. Regarding potential application, the results suggest a need for interventions that more effectively target demand Amplitude to make greater headway in reducing smoking in vulnerable populations. Trial Registration: clinicaltrials.gov identifiers: NCT02232737 , NCT02250664 , NCT02250534 .

Accumulating evidence suggests that the hypothetical Cigarette Purchase Task (CPT), especially its demand Intensity index (i.e., estimated cigarettes participants would smoke if free), is associated with individual differences in smoking risk. Nevertheless, few studies have examined the extent to which hypothetical CPT demand Intensity may differ from consumption when participants are provided with free cigarettes. That topic is the overarching focus of the present study. Participants were 745 adult smokers with co-morbid psychiatric conditions or socioeconomic disadvantage. CPT was administered for usual-brand cigarettes prior to providing participants with seven days of their usual-brand cigarettes free of cost and consumption was recorded daily via an Interactive Voice Response (IVR) System. Demand Intensity was correlated with IVR smoking rate (rs 0.670-0.696, ps 0.001) but estimates consistently exceeded IVR smoking rates by an average of 4.4 cigarettes per day (ps 0.001). Importantly, both measures were comparably sensitive to discerning well-established differences in smoking risk, including greater cigarettes per day among men versus women (F(1,732) = 18.74, p 0.001), those with versus without opioid-dependence (F(1,732) = 168.37, p 0.001), younger versus older adults (F(2,730) = 32.93, p 0.001), and those with lower versus greater educational attainment (F(1,732) = 38.26, p 0.001). Overall, CPT demand Intensity appears to overestimate consumption rates relative to those observed when participants are provided with free cigarettes, but those deviations are systematic (i.e., consistent in magnitude and direction, Fs all1.63; ps 0.19 for all interactions with subgroups). This suggests that demand Intensity was sensitive to established group differences in smoking rate, supporting its utility as an important measure of addiction potential.

Background Hypertrophic cardiomyopathy ( HCM ) is the most common inherited cardiomyopathy. Current guidelines endorse management in expert centers, but patient socioeconomic status can affect access to specialty care. The effect of socioeconomic status and specialty care access on HCM outcomes has not been examined. Methods and Results We conducted a retrospective cohort study that examined outcomes among HCM patients receiving care in the Yale New Haven Health System between June 2011 and December 2017. Patients were assigned to lower or higher socioeconomic status groups ( LSES / HSES ) based on medical insurance provider and to receivers of specialty care ( SC ) at Yale's Inherited Cardiomyopathy clinic or general cardiology care ( GC ). The primary outcome was all‐cause death, and the secondary outcome was all‐cause hospitalization. We identified 953 HCM patients; 820 (86%) were HSES and 133 (14%) were LSES . Forty‐three (4.5%) patients died from cardiac and noncardiac causes. LSES patients within the general cardiology care cohort had significantly higher all‐cause mortality compared with HSES patients (adjusted hazard ratio, [95% CI ]=10.06 [4.38–23.09]; P CI ]=2.87 [0.56–14.73]; P =0.21). The moderator effect of specialty care on mortality difference between LSES versus HSES , however, did not reach statistical significance (hazard ratio, 0.29 [0.05–1.77]; P =0.18). Specialist care was associated with increased hospitalization (adjusted hazard ratio, [95% CI ]=3.28 [1.11–9.73]; P =0.03 for LSES ; 2.19 [1.40–3.40]; P =0.001 for HSES ). Conclusions Socioeconomically vulnerable HCM patients had higher mortality when not referred to specialty care. Further study is needed to understand the underlying causes.

Research on food insecurity in Australia has typically relied on a single-item measure and finds that approximately 5% of the population experiences food insecurity. This research also finds that demographic characteristics such as household composition and marital status affect levels of food insecurity, independent of income level. The present study examines the prevalence and correlates of food insecurity in a cohort (n = 400) of people experiencing entrenched disadvantage in Perth, Western Australia. Using the US Department of Agriculture Household Food Security Survey Module, we find that food insecurity at the household, adult, and child level is at sharply elevated levels, with 82.8% of the sample reporting household food insecurity, 80.8% and 58.3% experiencing food insecurity among adults and children, respectively. Demographic characteristics do not significantly affect levels of food insecurity, and food insecurity is associated with negative physical and mental health outcomes. Food insecurity is positively correlated with access to food emergency relief services, indicating that these services are being used by those most in need, but do not address the root causes of food insecurity. Policy and practice should focus on increasing stable access to adequate quantities and quality of food and addressing the structural causes of food insecurity.

Background: Lung function is an important predictor of health and a marker of physical functioning at older ages. This study aimed to quantify the years of lung function lost according to disadvantaged socioeconomic conditions across life-course. Methods: This multicohort study used harmonised individual-level data from six European cohorts with information on life-course socioeconomic disadvantage and lung function assessed by FEV1 and FVC. 70496 participants (51% women) aged 18-93 years were included. Socioeconomic disadvantage was measured in early life (low paternal occupational position), early adulthood (low educational level), and adulthood (low occupational position). Risk factors for poor lung function (i.e., smoking, obesity, sedentary behaviour, cardiovascular and respiratory diseases) were included as potential mediators. The years of lung function lost due to socioeconomic disadvantage were computed at each life stage. Findings: Socioeconomic disadvantage during life-course was associated with a lower FEV1. By age 45, individuals experiencing disadvantaged socioeconomic conditions had lost 4 to 5 years of healthy lung function vs their more advantaged counterparts (low educational level: -4.36 [95% CI -7.33 to -2.37] for men and -5.14 [-10.32 to -2.71] for women; low occupational position: -5.62 [-7.98 to -4.90] for men and -4.32 [-13.31 to -2.27] for women), after accounting for the risk factors for lung function. By ages 65 and 85, the years lung function lost due to socioeconomic disadvantage decreased by 2 to 4 years, depending on the socioeconomic indicator. Interpretation: Life-course socioeconomic disadvantage is associated with lower lung function and predicts a considerable number of years of lung function loss in adulthood and older ages. Funding: Foundation for Science and Technology; European Commission; University of Lausanne; Medical Research Council; US National Institute on Aging; NordForsk; Helsinki Institute of Life Science; GlaxoSmithKline; Swiss National Science Foundation; Agence Nationale de la recherche. Declaration of Interests: None declared. Ethics Approval Statement: The relevant local or national ethics committees approved each study, and all participants gave written informed consent to participate.

Background People from socioeconomically disadvantaged population groups are less likely to be physically active and more likely to experience adverse health outcomes than those who are less disadvantaged. In this umbrella review we examined across all age groups, (1) the effectiveness of interventions to improve physical activity among socioeconomically disadvantaged groups, (2) the characteristics of effective interventions, and (3) directions for future research. Methods PubMed/MEDLINE and Scopus were searched up to May 2017 to identify systematic reviews reporting physical activity interventions in socioeconomically disadvantaged populations or sub-groups. Two authors independently conducted study screening and selection, data extraction (one author, with data checked by two others) and assessment of methodological quality using the ‘Assessment of Multiple Systematic Reviews’ scale. Results were synthesized narratively. Results Seventeen reviews met our inclusion criteria, with only 5 (30%) reviews being assessed as high quality. Seven (41%) reviews focused on obesity prevention and an additional four focused on multiple behavioural outcomes. For pre school children, parent-focused, group-based interventions were effective in improving physical activity. For children, school-based interventions and policies were effective; few studies focused on adolescents and those that did were generally not effective; for adults, there was mixed evidence of effectiveness but characteristics such as group-based interventions and those that focused on physical activity only were associated with effectiveness. Few studies focused on older adults. Across all ages, interventions that were more intensive tended to be more effective. Most studies reported short-term, rather than longer-term, outcomes and common methodological limitations included high probability of selection bias, low response rates, and high attrition. Conclusions Interventions can be successful at improving physical activity among children from socioeconomically disadvantaged groups, with evidence for other age groups weak or inconclusive. More high-quality studies in this population group are needed, which adopt strategies to increase recruitment rates and reduce attrition, report longer term outcomes, and provide adequate intervention details, to allow determination of the characteristics of effective interventions. We recommend that the benefits of physical activity be recognised more broadly than obesity prevention in future studies, as this may have implications for the design and appeal of interventions. Electronic supplementary material The online version of this article (10.1186/s12966-018-0676-2) contains supplementary material, which is available to authorized users.

Background and aim Direct-acting antiviral (DAA) treatments became available for all people living with hepatitis C virus (HCV) in Australia in March 2016. We assess variations in treatment rates and prescribing patterns across Australia's 338 Statistical Area 3 (SA3) geographical units. Methods Geocoded DAA treatment initiation data were analysed for the period 1 March 2016 to 30 June 2017. Regression models tested associations between the population demographics and healthcare service coverage of geographical areas and (a) their treatment rates; and (b) the proportion of prescriptions written by specialists compared to non-specialists. Results Across the 320 areas (95%) recording treatments, a median 76 (interquartile range [IQR] 35–207, range 4–3834) per 100,000 were initiated, corresponding to an estimated median 7.9% (IQR 2.9–23.6%, range 0–100%) treatment uptake. Major cities, areas of socioeconomic advantage and areas with lower proportions of the population born overseas had the highest per capita treatment rates. Non-specialists prescribed 46% (20,323/44,382) of treatment initiations. Prescriptions were written by non-specialists only in 163 areas (51%), while in other areas a median 40.0% (IQR 21.8–62.5%) of prescriptions were written by non-specialists. Non-specialist prescribing was higher in regional areas, as well as areas that had greater proportions of Indigenous Australians. Conclusions High national-level treatment uptake of 20% in Australia masks underlying health system limitations; more than half of geographical areas may have treated less than 8% of people living with HCV. Areas of socioeconomic disadvantage and areas with a higher proportion of the population born overseas may need targeting with interventions to improve treatment uptake.

Purpose Heart failure (HF) disproportionally affects racial minorities and disparities in access to therapies exist. Recent work suggests greater use of left ventricular assist devices (LVAD) among African American (AA) patients compared to white patients that likely remains disparate due to a higher prevalence of HF in AA. We sought to understand disparities in LVAD use by race among a cohort of patients with similar HF severity and explore the impact of socioeconomic disadvantage. Methods We analyzed fee-for-service Medicare claims among 311,265 beneficiaries admitted with a principal diagnosis of systolic HF between 2008-2014. Inpatient and outpatient claims in prior 6 months used to estimate propensity for LVAD treatment using synthetic minority over-sampling, a machine learning method. Beneficiaries with ≥70% predicted probability of receiving an LVAD were included. These results were applied to model disparities using logistic regression with LVAD use and 1-year survival with and without LVAD among AA and white recipients as the dependent variables. Model covariates included race, clinical characteristics, distance from LVAD center, and year. After confirming a disparity, the Medicare low-income subsidy included to explore impact of socioeconomic disadvantage. Results The sample included 15,406 observations, of whom 45.2% (n=6,967) received an LVAD. AA were 23.6% (n=3,648) of the population and 21.8% (n=1,520) of LVAD recipients. One-year survival was 73% with LVAD and 62% without. Compared to white patients, AA patients matched for the propensity to receive an LVAD were 4.0% less likely to receive the therapy (95% CI -5.1 to -1.7; p Conclusion Disparities in the use of LVAD for AA Medicare beneficiaries with HF exist that are not entirely explained by socioeconomic disadvantage. These data suggest that other factors are impacting the application of LVAD therapy in AA patients. Potential explanations include racial biases or systemic racism that influence clinician decision-making or patient preferences.

The aim of the “Smuovi La Salute” (“Shake Your Health”) project was to implement an integrated and comprehensive model to prevent and treat overweight and obesity in low socioeconomic status (SES) and minority groups living in three different districts in the north of Italy. An app and a cookbook promoting transcultural nutrition and a healthy lifestyle were developed, and no-cost physical activities were organized. Healthy lifestyle teaching was implemented in 30 primary school classrooms. Learning was assessed through pre- and post-intervention questionnaires. At the Obesity Pediatric Clinic, overweight and obese children of migrant background or low SES were trained on transcultural nutrition and invited to participate in the project. Primary school students increased their knowledge about healthy nutrition and the importance of physical activity (p-value &lt, 0.001). At the Obesity Pediatric Clinic, after 6 months, pre–post-intervention variation in their consumption of vegetables and fruit was +14% (p &lt, 0.0001) and no variation in physical activity habits occurred (p = 0.34). In this group, the BMI z-score was not significantly decreased (−0.17 ± 0.63, p= 0.15). This study demonstrates the feasibility and efficacy of telematic tools and targeted community approaches in improving students’ knowledge with regard to healthy lifestyle, particularly in schools in suburbs with a high density of migrants and SES families. Comprehensive and integrated approaches provided to the obese patients remain mostly ineffective.

Perinatal asphyxia remains one of the major causes of morbidity and mortality for term newborns. Though access to health care and birth attendants have decreased the rate, Neonatal encephalopathy (NE) has not been eliminated. Worldwide, women at socioeconomic disadvantage have the highest risk of delivering a neonate with NE. Neonates that will experience perinatal asphyxia cannot be easily identified prospectively and the intrapartum testing available is not specific enough to clearly indicate the best course of action in most cases. Despite this, training programs that aim to decrease morbidity and mortality from all causes appear to be associated with fewer cases of perinatal asphyxia. The current best approach is to support education and communication for all people involved in the care of birthing women. Ideally, new technology will address identification of the fetus likely to be affected or the fetus who is beginning to experience injury in advance of delivery.