Protocol of the baseline assessment for the Environments for Healthy Living (EHL) Wales cohort study

Identifying Prenatal and Postnatal Determinants of Infant Growth: A Structural Equation Modelling Based Cohort Analysis

Background: The growth and maturation of infants reflect their overall health and nutritional status. The purpose of this study is to examine the associations of prenatal and early postnatal factors with infant growth (IG). Methods: A data-driven model was constructed by structural equation modelling to examine the relationships between pre- and early postnatal environmental factors and IG at age 12 months. The IG was a latent variable created from infant weight and waist circumference. Data were obtained on 274 mother–child pairs during pregnancy and the postnatal periods. Results: Maternal pre-pregnancy BMI emerged as an important predictor of IG with both direct and indirect (mediated through infant birth weight) effects. Infants who gained more weight from birth to 6 months and consumed starchy foods daily at age 12 months, were more likely to be larger by age 12 months. Infant physical activity (PA) levels also emerged as a determinant. The constructed model provided a reasonable fit (χ² (11) = 21.5, p < 0.05; RMSEA = 0.07; CFI = 0.94; SRMR = 0.05) to the data with significant pathways for all examined variables. Conclusion: Promoting healthy weight amongst women of child bearing age is important in preventing childhood obesity, and increasing daily infant PA is as important as a healthy infant diet.

Parent recommendations to support physical activity for families with young children: Results of interviews in deprived and affluent communities in South Wales (United Kingdom)

BACKGROUND

Physical inactivity is the fourth leading cause of mortality worldwide. Early childhood is a critical period when healthy behaviours can be instilled for a future active lifestyle. We explored community, societal and environmental factors affecting child and family physical activity and sought parent recommendations to support physical activity in families with young children.

METHODS

We interviewed 61 parents expecting a child or with a baby ≤12 months (35 mother and father paired interviews and 26 interviews with mothers only). We purposively sampled families for neighbourhood deprivation status (Townsend Index; 26 affluent; 35 deprived). We conducted thematic analysis of interview transcripts using Bronfenbrenner's socio-ecological framework to guide interpretation.

RESULTS

We identified four themes: work family-life balance; spaces for activity; beliefs and attitudes; and physical activity facilitators. We found that parents from deprived neighbourhoods were more likely to be underactive because of a complex web of community, social and personal factors which reduced motivation and hindered opportunity for physical activity. To increase knowledge and opportunity, respondents suggested 'help not tell' messages covering 'why', 'how' and 'where' information about physical activity, and using physical activity to support community engagement and social interaction.

CONCLUSIONS

Recommendations from parents highlight effective communication about the importance of early child and family physical activity and improved community access to safe facilities and opportunities. Both parents need to be engaged in designing interventions to support greater physical activity and healthy behaviours which are relevant and achievable in individuals' lives.

Predictors of objectively measured physical activity in 12-month-old infants: A study of linked birth cohort data with electronic health records

BACKGROUND

Physical activity (PA) levels are associated with long-term health, and levels of PA when young are predictive of adult activity levels.

OBJECTIVES

This study examines factors associated with PA levels in 12-month infants.

METHOD

One hundred forty-one mother-infant pairs were recruited via a longitudinal birth cohort study (April 2010 to March 2013). The PA level was collected using accelerometers and linked to postnatal notes and electronic medical records via the Secure Anonymised Information Linkage databank. Univariable and multivariable linear regressions were used to examine the factors associated with PA levels.

RESULTS

Using univariable analysis, higher PA was associated with the following (P value less than 0.05): being male, larger infant size, healthy maternal blood pressure levels, full-term gestation period, higher consumption of vegetables (infant), lower consumption of juice (infant), low consumption of adult crisps (infant), longer breastfeeding duration, and more movement during sleep (infant) but fewer night wakings. Combined into a multivariable regression model (R2  = 0.654), all factors remained significant, showing lower PA levels were associated with female gender, smaller infant, preterm birth, higher maternal blood pressure, low vegetable consumption, high crisp consumption, and less night movement.

CONCLUSION

The PA levels of infants were strongly associated with both gestational and postnatal environmental factors. Healthy behaviours appear to cluster, and a healthy diet was associated with a more active infant. Boys were substantially more active than girls, even at age 12 months. These findings can help inform interventions to promote healthier lives for infants and to understand the determinants of their PA levels.

Obesity in pregnancy: infant health service utilisation and costs on the NHS

OBJECTIVE

To estimate the direct healthcare cost of infants born to overweight or obese mothers to the National Health Service in the UK.

DESIGN

Retrospective prevalence-based study.

SETTING

Combined linked anonymised electronic data sets on a cohort of mother-child pairs enrolled on the Growing Up in Wales: Environments for Healthy Living (EHL) study. Infants were categorised according to maternal early-pregnancy body mass index (BMI): healthy weight mother (18.5≤BMI<25 kg/m(2); n=342), overweight mother (25≤BMI≤29.9 kg/m(2); n=157) and obese mother (BMI≥30; n=110).

PARTICIPANTS

609 singleton pregnancies with available health service records and an antenatal maternal BMI.

PRIMARY OUTCOME MEASURE

Total health service utilisation and direct healthcare costs for providing these services in the year 2012-2013. Costs are calculated as cost of the infant (no maternal costs considered) and are related to health service usage from birth to age 1 year.

RESULTS

A strong association existed between healthcare usage cost and BMI (p<0.001). Mean total costs were 72% higher among children born to obese mothers (rate ratio (RR) 1.72, 95% CI 1.71 to 1.73) compared with infants born to healthy weight mothers. Higher costings were attributed to a significantly greater number (RR 1.39, 95% CI 1.04 to 1.84) and duration (RR 1.55, 95% CI 1.37 to 1.74) of inpatient visits and a higher number of general practitioner visits (RR 1.10, 95% CI 1.03 to 1.16). Total mean additional resource cost was estimated at £65.13 for infants born to overweight mothers and £1138.11 for infants born to obese mothers, when compared with infants of healthy weight mothers.

CONCLUSIONS

Increasingly infants born to mothers with high BMIs consume additional health service resources in the first year of life; this was apparent across inpatient and general practitioner services. Considering both maternal and infant health service use, interventions that cost less than £2310 per person in reducing obesity early pregnancy could be cost-effective.

Análisis de los factores medio ambientales condicionantes de la inocuidad de hortalizas cultivadas y consumidos en el área rural de Tenjo, Cundinamarca

<p class="MsoCommentText" style="text-align: justify; line-height: 150%;"><span style="font-family: ";Arial";,";sans-serif";; mso-ansi-language: ES;" lang="ES">La seguridad alimentaria y nutricional propende por la garantía de alimentos de calidad para todos. La carencia de inocuidad puede ser la causa de enfermedades transmitidas por alimentos que afectan no sólo la calidad de vida sino el estado nutricional de los consumidores. El estudio de los factores medioambientales que determinan la inocuidad de las hortalizas que se cultivan y se consumen en el municipio de Tenjo, Cundinamarca, se constituye en el objeto del presente trabajo.</span></p> <p class="MsoCommentText" style="text-align: justify; line-height: 150%;"><span style="font-family: ";Arial";,";sans-serif";; mso-ansi-language: ES;" lang="ES">El trabajo se desarrolló en tres fases: inicialmente se efectuó una revisión, análisis y búsqueda documental sistemática en bases de datos y fuentes documentales impresas; seguidamente se realizó el trabajo de campo dividido en dos tipos de actividades: visitas a cultivos tradicionales y orgánicos de hortalizas en el municipio para poder establecer diferencias entre ellos, y encuestas a los consumidores de las mismas en Tenjo y Bogotá para establecer patrones de compra y consumo de éstos alimentos. Por último, se realizó el análisis de los datos obtenidos y se identificaron los peligros y puntos críticos de control para proponer los correctivos necesarios.</span></p> <p class="MsoNormal" style="text-align: justify; line-height: 150%; mso-layout-grid-align: none; text-autospace: none;"><span style="font-size: 10.0pt; line-height: 150%; font-family: ";Arial";,";sans-serif";; mso-ansi-language: ES;" lang="ES">Se encontró que los principales factores medioambientes que determinan las condiciones de inocuidad de las hortalizas de Tenjo son el agua que se utiliza en el riego, las sustancias que se emplean para fertilizar el suelo y controlar las plagas, los empaques o embalajes para la distribución y venta del producto y finalmente, la manipulación de las hortalizas por parte de los consumidores. </span></p>

Parental recommendations for population level interventions to support infant and family dietary choices: a qualitative study from the Growing Up in Wales, Environments for Healthy Living (EHL) study

Background

Childhood obesity presents a challenge to public health. This qualitative study explored the main barriers to dietary choices faced by parents with infants, and the types of interventions and policy level recommendations they would like to see put in place, to promote a healthier food environment.

Methods

61 semi-structured interviews with prospective parents and parents of infants (61 mothers and 35 fathers) were conducted. Families were selected according to community deprivation levels using the Townsend Deprivation Index to ensure a representative sample from deprived and affluent neighbourhoods. Inductive thematic analysis was used to analyse the data.

Results

Parents identified triggers which led to unhealthy dietary choices such as reliance on fast food outlets due to; shift work, lack of access to personal transport, inability to cook, their own childhood dietary experiences, peer pressure and familial relationships. Parents who made healthy dietary choices reported learning cooking skills while at university, attending community cooking classes, having access to quality food provided by church and community organisations or access to Healthy Start vouchers. They called for a reduction in supermarket promotion of unhealthy food and improved access to affordable and high-quality fresh produce in the local area and in supermarkets. There was a strong message to policy makers to work with commercial companies (food manufactures) as they have resources to lower costs and target messages at a diverse population. Provision of targeted advice to fathers, minority ethnic parents, and tailored and practical advice and information on how to purchase, prepare, store and cook food was requested, along with community cookery classes and improved school cookery lessons.

Conclusions

There is a need for parent directed community/population level interventions that aims to reduce socio-ecological barriers to making healthy dietary choices. Parents desired improvements in meals provided in workplaces, schools and hospitals, as well as increased access to healthy foods by increasing local healthy food outlets and reducing unhealthy, fast food outlets. Knowledge and skills could then be enhanced in line with these improvements, with confidence gained around cooking and storing food appropriately.

Suicide Information Database-Cymru: a protocol for a population-based, routinely collected data linkage study to explore risks and patterns of healthcare contact prior to suicide to identify opportunities for intervention

INTRODUCTION

Prevention of suicide is a global public health challenge extending beyond mental health services. Linking routinely collected health and social care system data records for the same individual across different services and over time has enormous potential in suicide research. Most previous research linking suicide mortality data with routinely collected electronic health records involves only one or two domains of healthcare provision such as psychiatric inpatient care. This protocol paper describes the development of a population-based, routinely collected data linkage study: the Suicide Information Database Cymru (SID-Cymru). SID-Cymru aims to contribute to the information available on people who complete suicide.

METHODS AND ANALYSIS

SID-Cymru will facilitate a series of electronic case-control studies based in the Secure Anonymised Information Linkage (SAIL) Databank. We have identified 2664 cases of suicide in Wales between 2003 and 2011 from routinely collected mortality data using International Classification of Diseases, Tenth Revision, codes X60-X84 (intentional self-harm) and Y10-Y34 (undetermined intent). Each case will be matched by age and sex to at least five controls. Records will be collated and linked from routinely collected health and social data in Wales for each individual. Conditional logistic regression will be applied to produce crude and confounder (including general practice, socioeconomic status) adjusted ORs.

ETHICS AND DISSEMINATION

The SAIL Databank has the required ethical permissions in place to analyse anonymised data. Ethical approval has been granted by the Information Governance Review Panel (IGRP). Findings will be disseminated through peer-reviewed publications, consultations with stakeholders and national/international conference presentations. The improved understanding of the prior health, nature of previous contacts with services and wider social circumstances of those who complete suicide will assist in prevention policy, service organisation and delivery. SID-Cymru is funded through the National Institute for Social Care and Health Research, Welsh Government (RFS-12-25).

Physical activity and excess weight in pregnancy have independent and unique effects on delivery and perinatal outcomes

Background

This study examines the effect of low daily physical activity levels and overweight/obesity in pregnancy on delivery and perinatal outcomes.

Methods

A prospective cohort study combining manually collected postnatal notes with anonymised data linkage. A total of 466 women sampled from the Growing Up in Wales: Environments for Healthy Living study. Women completed a questionnaire and were included in the study if they had an available Body mass index (BMI) (collected at 12 weeks gestation from antenatal records) and/or a physical activity score during pregnancy (7-day Actigraph reading). The full statistical model included the following potential confounding factors: maternal age, parity and smoking status. Main outcome measures included induction rates, duration of labour, mode of delivery, infant health and duration of hospital stay.

Findings

Mothers with lower physical activity levels were more likely to have an instrumental delivery (including forceps, ventouse and elective and emergency caesarean) in comparison to mothers with higher activity levels (adjusted OR:1.72(95%CI: 1.05 to 2.9)). Overweight/obese mothers were more likely to require an induction (adjusted OR:1.93 (95%CI 1.14 to 3.26), have a macrosomic baby (adjusted OR:1.96 (95%CI 1.08 to 3.56) and a longer hospital stay after delivery (adjusted OR:2.69 (95%CI 1.11 to 6.47).

Conclusions

The type of delivery was associated with maternal physical activity level and not BMI. Perinatal outcomes (large for gestational age only) were determined by maternal BMI.

Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS

OBJECTIVE

To estimate the direct healthcare cost of being overweight or obese throughout pregnancy to the National Health Service in Wales.

DESIGN

Retrospective prevalence-based study.

SETTING

Combined linked anonymised electronic datasets gathered on a cohort of women enrolled on the Growing Up in Wales: Environments for Healthy Living (EHL) study. Women were categorised into two groups: normal body mass index (BMI; n=260) and overweight/obese (BMI>25; n=224).

PARTICIPANTS

484 singleton pregnancies with available health service records and an antenatal BMI.

PRIMARY OUTCOME MEASURE

Total health service utilisation (comprising all general practitioner visits and prescribed medications, inpatient admissions and outpatient visits) and direct healthcare costs for providing these services in the year 2011-2012. Costs are calculated as cost of mother (no infant costs are included) and are related to health service usage throughout pregnancy and 2 months following delivery.

RESULTS

There was a strong association between healthcare usage cost and BMI (p<0.001). Adjusting for maternal age, parity, ethnicity and comorbidity, mean total costs were 23% higher among overweight women (rate ratios (RR) 1.23, 95% CI 1.230 to 1.233) and 37% higher among obese women (RR 1.39, 95% CI 1.38 to 1.39) compared with women with normal weight. Adjusting for smoking, consumption of alcohol, or the presence of any comorbidities did not materially affect the results. The total mean cost estimates were £3546.3 for normal weight, £4244.4 for overweight and £4717.64 for obese women.

CONCLUSIONS

Increased health service usage and healthcare costs during pregnancy are associated with increasing maternal BMI; this was apparent across all health services considered within this study. Interventions costing less than £1171.34 per person could be cost-effective if they reduce healthcare usage among obese pregnant women to levels equivalent to that of normal weight women.

Longitudinal follow-up of the relationship between dietary intake and growth and development in the Lifeways cross-generation cohort study 2001-2013

In this paper we will review evidence on the early life and familial influences on childhood growth and development, with particular reference to the Lifeways cross-generation cohort study in the Republic of Ireland. The Lifeways cross-generation cohort study was established in 2001-2013 through two maternity hospitals in the Republic of Ireland and was one of many new cohort studies established worldwide in the millennium period. Mothers were recruited at first booking visit, completing a self-administered questionnaire, which included a 147 item semi-quantitative FFQ. Longitudinal follow-up is ongoing in 2013, with linkage data to hospital and general practice records and examination of children when aged 5 and 9 years. The study is one of very few containing data on grandparents of both lineages with at least one grandparent recruited at baseline. There have been consistent associations between parental and grandparental health status characteristics and children's outcomes, including infant birth-weight, BMI when child was aged 5 years and childhood wheeze or asthma when child was aged 3 and aged 5 years. In conclusion, empirical evidence to date shows consistent familial and cross-generational patterns, particularly in the maternal line.

Mothers' perspectives on the delivery of childhood injury messages: a qualitative study from the growing up in Wales, environments for healthy living study (EHL)

BACKGROUND

Childhood injury is the second leading cause of death for infants aged 1-5 years in the United Kingdom (UK) and most unintentional injuries occur in the home. We explored mothers' knowledge and awareness of child injury prevention and sought to discover mothers' views about the best method of designing interventions to deliver appropriate child safety messages to prevent injury in the home.

METHODS

Qualitative study based on 21 semi-structured interviews with prospective mothers and mothers of young children. Mothers were selected according to neighbourhood deprivation status.

RESULTS

There was no difference in awareness of safety devices according to mothers' deprivation status. Social networks were important in raising awareness and adherence to child safety advice. Mothers who were recent migrants had not always encountered safety messages or safety equipment commonly used in the UK. Mothers' recommended that safety information should be basic and concise, and include both written and pictorial information and case studies focus on proactive preventive messages. Messages should be delivered both by mass media and suitably trained individuals and be timed to coincide with pregnancy and repeated at age appropriate stages of child development.

CONCLUSIONS

The findings suggest that timely childhood injury-related risk messages should be delivered during pregnancy and in line with developmental milestones of the child, through a range of sources including social networks, mass media, face-to-face advice from health professionals and other suitably trained mothers. In addition information on the safe use of home appliances around children and use of child safety equipment should be targeted specifically at those who have recently migrated to the United Kingdom.

Pregnancy and birth cohort resources in europe: a large opportunity for aetiological child health research

BACKGROUND

During the past 25 years, many pregnancy and birth cohorts have been established. Each cohort provides unique opportunities for examining associations of early-life exposures with child development and health. However, to fully exploit the large amount of available resources and to facilitate cross-cohort collaboration, it is necessary to have accessible information on each cohort and its individual characteristics. The aim of this work was to provide an overview of European pregnancy and birth cohorts registered in a freely accessible database located at http://www.birthcohorts.net.

METHODS

European pregnancy and birth cohorts initiated in 1980 or later with at least 300 mother-child pairs enrolled during pregnancy or at birth, and with postnatal data, were eligible for inclusion. Eligible cohorts were invited to provide information on the data and biological samples collected, as well as the timing of data collection.

RESULTS

In total, 70 cohorts were identified. Of these, 56 fulfilled the inclusion criteria encompassing a total of more than 500,000 live-born European children. The cohorts represented 19 countries with the majority of cohorts located in Northern and Western Europe. Some cohorts were general with multiple aims, whilst others focused on specific health or exposure-related research questions.

CONCLUSION

This work demonstrates a great potential for cross-cohort collaboration addressing important aspects of child health. The web site, http://www.birthcohorts.net, proved to be a useful tool for accessing information on European pregnancy and birth cohorts and their characteristics.

Environments for Healthy Living (EFHL) Griffith birth cohort study: background and methods

The health of an individual is determined by the interaction of genetic and individual factors with wider social and environmental elements. Public health approaches to improving the health of disadvantaged populations will be most effective if they optimise influences at each of these levels, particularly in the early part of the life course. In order to better ascertain the relative contribution of these multi-level determinants there is a need for robust studies, longitudinal and prospective in nature, that examine individual, familial, social and environmental exposures. This paper describes the study background and methods, as it has been implemented in an Australian birth cohort study, Environments for Healthy Living (EFHL): The Griffith Study of Population Health. EFHL is a prospective, multi-level, multi-year longitudinal birth cohort study, designed to collect information from before birth through to adulthood across a spectrum of eco-epidemiological factors, including genetic material from cord-blood samples at birth, individual and familial factors, to spatial data on the living environment. EFHL commenced the pilot phase of recruitment in 2006 and open recruitment in 2007, with a target sample size of 4000 mother/infant dyads. Detailed information on each participant is obtained at birth, 12-months, 3-years, 5-years and subsequent three to five yearly intervals. The findings of this research will provide detailed evidence on the relative contribution of multi-level determinants of health, which can be used to inform social policy and intervention strategies that will facilitate healthy behaviours and choices across sub-populations.

Protocol for a population-based ankylosing spondylitis (PAS) cohort in Wales

Background

To develop a population-based cohort of people with ankylosing spondylitis (AS) in Wales using (1) secondary care clinical datasets, (2) patient-derived questionnaire data and (3) routinely-collected information in order to examine disease history and the health economic cost of AS.

Methods

This data model will include and link (1) secondary care clinician datasets (i.e. electronic patient notes from the rheumatologist) (2) patient completed questionnaires (giving information on disease activity, medication, function, quality of life, work limitations and health service utilisation) and (3) a broad range of routinely collected data (including; GP records, in-patient hospital admission data, emergency department data, laboratory/pathology data and social services databases). The protocol involves the use of a unique and powerful data linkage system which allows datasets to be interlinked and to complement each other.

Discussion

This cohort can integrate patient supplied, primary and secondary care data into a unified data model. This can be used to study a range of issues such as; the true economic costs to the health care system and the patient, factors associated with the development of severe disease, long term adverse events of new and existing medication and to understand the disease history of this condition. It will benefit patients, clinicians and health care managers. This study forms a pilot project for the use of routine data/patient data linked cohorts for other chronic conditions.