(From the ISHN Member information service)  An article in December 2014 Issue of BMC Public Health examined the potential impact of several non-pharmaceutical strategies for responding to influenza outbreaks. These included school closures, work place closures, travel restrictions, voluntary and obligatory quarantines and more. The most effective non-pharma response to such outbreaks was closing any school quickly when infections reached a certain level. The authors conclude that "Our methodology was able to design effective NPI strategies, which were able to contain outbreaks by reducing infection attack rates (IAR) to below 10% in low and medium virus transmissibility scenarios with 33% and 50% IAR, respectively. The level of reduction in the high transmissibility scenario (with 65% IAR) was also significant. As noted in the published literature, we also found school closure to be the single most effective intervention among all NPIs". Read more>>  

(From the ISHN Member information service)   The eight-part ISHN model for the system/organizational capacity in sustaining comprehensive, multi-intervention approaches includes the concept of "explicit planning for sustainability". An article in the January 2015 issue of Prevention Science reports on sustainability of evidence-based programs in a variety of settings, including schools. Explicit sustainability planning was among the list of features that helped to sustain programs at least two years after the external funding or support is removed. The authors note that " Despite its obvious importance, sustainability has received relatively little attention in prevention science until recently. Moreover, there have been few opportunities to study the correlates of sustainability in large-scale, multi-year initiatives involving multiple programs. The present study examined rates of sustainment of a wide range of proven-effective prevention and intervention programs; identified factors related to organizational support and readiness, program and implementer characteristics, and sustainability planning that distinguished sustained programs; and examined variability in these associations across classroom-based, community/mentoring, family-focused prevention, and family treatment program types within the context of a state-wide EBP dissemination initiative in Pennsylvania over 4 years. The majority of EBPs sustained functioning 2 years or more beyond their initial funding. In general, sustained programs reported greater community coalition functioning, communication to key stakeholders, knowledge of the program's logical model, communication with the trainer or program developer, and sustainability planning. In addition to these universal correlates, important program-specific correlates emerged as well." Read more>>

(From the ISHN Member information service)   An editorial in the January 2015 issue Cochrane Database Systematic Reviews discusses the challenges of reviews of complex interventions such as school health promotion. Although the editorial is discussing coordinated case management of dementia patient care, the comments will likely apply to the complexity of reviewing the variable, multiple, coordinated interventions required in school health promotion. 
The authors suggest that "Guidelines have recommended the use of case management but are cautious about the evidence, judged as at least partially inconclusive.There is also uncertainty about the most suitable components of case management interventions.This is no surprise as case management is a prototypical example of a complex intervention. There is complexity in the intervention components as well as in the theoretical background of the intervention, the implementation context, and the targeted outcomes. As with many complex interventions, case management also targets more than one recipient: people with dementia and/or their carers. The challenges of synthesising the evidence for complex interventions have been acknowledged by Cochrane, with a recent series of articles forming the basis for an upcoming new chapter in the Cochrane Handbook for Systematic Reviews of Interventions." 
The authors laud the particular review of dementia with comments that could be applied to the variations in school health promotion; " Comprehensive tables allow readers to compare the goals of case management interventions, components of case management and control interventions, methods of intervention implementation, tasks and components of case management, and outcome measures used. Interventions are also categorised into three different approaches to case management. Still, for many studies there is not enough information to clearly describe what has been done. Also, case management interventions were often implemented as a part of wider health system changes, making it more difficult to attribute observations to case management, let alone to distinct components of case management interventions.". 
The authors also make suggestions for reviews of complex interventions that also apply to school health and other school-related strategies; "Guidance on conducting systematic reviews of complex interventions often demands the inclusion of further studies to allow for in-depth descriptions of study components and the context and process of implementing the intervention. This frequently requires the inclusion of mixed-method or qualitative studies that could help to disentangle the intervention components and their distinct roles. While this undoubtedly adds to Cochrane authors' already demanding workload, it seems essential if the most meaningful use is to be made of the data. Reporting is a problem, and information is often difficult or even impossible to acquire. Recent reporting guidelines may help authors look for important aspects concerning the intervention (TIDieR guideline) or the whole process of complex intervention development and evaluation (CReDECI guideline)" 
They also mention other problems; "Apart from the problems described above, the present review suffers from the fact that most studies are fairly small, with fewer than 100 participants per group in all but one study". We would add that the time period for assessing school health approaches is also problematic. A truly comprehensive, ecological and systems-based approach to SH does more than examine a few schools or some selected interventions. it is an approach that is developed over several years at a national or sate level, with the delivery of multiple policies, funding, personnel and programs from several ministries, local agencies/school boards and then local professionals as well as the people working in the school building. Indeed, reviews of school health promotion and social development are actually far more complex than the one discussed in this editorial, which examines coordinated case management of a single health problem. 
It is in the light of this January 2015 Cochrane editorial that we can turn to two major recent and previous reviews of school health promotion (Langford et al, 2014; Stewart-Brown, 2006) and understand better why both of these reviews as well as others conclude that SH promotion is promising but there is insufficient evidence. For further discussion, readers might want to listen to our recent October 23, 2014 ISHN webinar with the authors of the most recent review, as it discusses the limits of RCT studies and the ensuing systematic reviews even further.  We hereby challenge researchers and research funding organizations to address this challenge, perhaps beginning with the impending Cochrane Handbook Chapter on complex interventions. 

(From the ISHN Member information service)  It is always nice to find someone that agrees with you. It is also disconcerting to find that they made the point before you. Our analysis of the WHO 2013-20 action plan on NCD noted that it, and the health ministries around the world, were retreating from a population, health promotion approach to a narrow, medical strategy. Our ongoing review of journals found a similar, earlier argument in the 2014 issue of Global health Action. The author, writing in a series on the medicalization of global health, comments on the "medicalization of NCD efforts". She says "The 2011 UN Summit, WHO 25×25 targets, and support of major medical and advocacy organisations have propelled prominence of NCDs on the global health agenda. NCDs are by definition ‘diseases’ so already medicalized. But their social drivers and impacts are acknowledged, which demand a broad, whole-of-society approach. However, while both individual- and population-level targets are identified in the current NCD action plans, most recommended strategies tend towards the individualistic approach and do not address root causes of the NCD problem. These so-called population strategies risk being reduced to expectations of individual and behavioural change, which may have limited success and impact and deflect attention away from government policies or regulation of industry. Industry involvement in NCD agenda-setting props up a medicalized approach to NCDs: food and drink companies favour focus on individual choice and responsibility, and pharmaceutical and device companies favour calls for expanded access to medicines and treatment coverage. Current NCD framing creates expanded roles for physicians, healthcare workers, medicines and medical monitoring. The challenge and opportunity lie in defining priorities and developing strategies that go beyond a narrow medicalized framing of the NCD problem and its solutions". Read more>>

(From the ISHN Member information service)  The WHO released its 2013-2020 Action Plan on Non-Communicable Disease (NCD) prevention in January 2015. This commentary looks into the document from the perspective of the latest knowledge we have on school health promotion. 

The action plan states "The action plan provides a road map and a menu of policy options for all Member States and other stakeholders, to take coordinated and coherent action, at all levels, local to global, to attain the nine voluntary global targets, including that of a 25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025. 6. The main focus of this action plan is on four types of noncommunicable disease—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—which make the largest contribution to morbidity and mortality due to noncommunicable diseases, and on four shared behavioural risk factors—tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. It recognizes that the conditions in which people live and work and their lifestyles influence their health and quality of life" It is in this last sentence where the action plan fails. quite badly. In this analysis, we look more closely at the words in the document and then discuss one aspect drawing from the recent evidence and experience in school health promotion. 

The vision described on page 12 of the document is revealing. it begins with the goal " A world free of the avoidable burden of noncommunicable diseases". Nowhere does the document contain the WHO vision of health, which, as we know, is "more than the absence of disease". The vision contains several nice concepts, including human rights, equity, national multi-sectorial action, life-course approach, empowerment, and managing potential conflicts of interest with food companies and others. But the implicit nature of the document becomes clearer when we note that the words population health, public health u or health promotion are not used. As well, the agenda becomes clearer when we note that of the five functions of public health (protection, promotion, prevention, services and surveillance) only universal health services is mentioned. The WHO intent in this document is clearly to galvanize action in countries in a disease prevention strategy. The first objective of the action plan (p. 5) is to "raise the priority accorded to the prevention and control of NCD's".  This action plan really is about disease, and building the case for for access to universal health care. In our view, the document is part of and reflects a world wide trend for the health sector to retreat back to a medical model and move away from the principles of the Ottawa and ensuing charters related to health promotion and social development.  

We will come back to the vision statement about evidence-based strategies later in this analysis.  

As proponents of school health promotion and settings-based work, we were hopeful when we read on page 5 of the objective stating " to reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting
environments." If there is any chance that WHO and the health ministries in countries are to secure the cooperation of other sectors in the Health in All Policies (HiAP) initiatives, then the health sector will need to "go to where those sectors do their work, ie in the settings where people live, learn, work and play. However, when we got to pages 29-37, we found no mention of healthy cities/communities, schools, workplaces, hospitals, universities and other settings. We found only recommended actions such as legislation on second-hand smoke, warnings on cigarette packages, controls on food marketing, promotion of physical activity guidelines and limitations on alcohol sales. These are all good things but they are also all "prescriptions" (medical pun intended) for behaviour change. This medical model has long been discredited in the research on behaviour change and, more recently, even more so on our growing understanding of ecological and systems-based approaches. 

The document does suggest that the WHO Secretariat should provide technical assistance to countries through settings such as schools, cities, recreation etc but the investment (or re-investment) by countries in these settings-based strategies as the means to deliver the NCD prevention strategy is clearly not included as part of the recommended action by countries. Further, when we know that the current total investment of the global WHO office for working with all of these settings is one staff person, we must question the feasibility of the intent to provide such technical assistance.  

In closing, we will pick out one aspect of the action plan that further illustrates how the WHO action plan is actually more of a medically-inspired, bureaucratic creation rather than being based on research evidence and professional experience in the real world. On page  33, we find recommendations that suggest countries should promote "active transportation" and "Improved provision of quality physical education in educational settings (from infant years to tertiary level) including opportunities for physical activity before, during and after the formal school day." If you are a reader of this blog you will recall that we have been tracking the research and reports on physical activity, particularly in regards to its connection to obesity/overweight. Based on several research reviews and articles, we now know that increased physical activity alone, has little effect on body weight. We also know that increased PE time does little to increase actual moderate/vigorous activity unless PE classes are transformed. We know that extensive school-based obesity prevention programs have not reduced obesity levels. We know that we can squeeze out more minutes of activity for some students through active recess, after-school and in-class activities but these efforts do not always engage the naturally less active or uncoordinated students. We know that walking and biking to schools is the best way to accumulate activity minutes. But we also know that structural barriers (perceived safety, parent work schedules, existing neighbourhood designs all prevent significant change in transportation patterns. 


We also know that these economic and social barriers to active transportation to school may actually illustrate the more fundamental, deeper analysis that is missing throughout the WHO action plan.  For example, a recent analysis of active school transportation in California notes that poor children are the ones most walking to school and they are also the ones that are more obese and overweight. As well, these poor children, who now comprise over one-half of the school children in the United States, actually have more urgent and important health problems. If we retreat to a medical, prescriptive model, one that ignores what we have learned about behaviour and ecological influences in the past two decades, then all of the words in documents like the NCD plan will be much less useful in the real world. 

(From the ISHN Member information service)  The WHO fact sheet describing the response of health ministries to prevent and control NCDs indicates the collective, global intentions and strategies. The ideas and actions not mentioned on the page and in the action plan are as important as the ones that are highlighted. WHO summarizes the actions needed as follows:
" To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them. An important way to reduce NCDs is to focus on lessening the risk factors associated with these diseases. Low-cost solutions exist to reduce the common modifiable risk factors (mainly tobacco use, unhealthy diet and physical inactivity, and the harmful use of alcohol) and map the epidemic of NCDs and their risk factors. Other ways to reduce NCDs are high impact essential NCD interventions that can be delivered through a primary health-care approach to strengthen early detection and timely treatment. Evidence shows that such interventions are excellent economic investments because. The greatest impact can be achieved by creating healthy public policies that promote NCD prevention and control and reorienting health systems. Lower-income countries generally have lower capacity for prevention and control. Countries with inadequate health insurance coverage are unlikely to provide universal access to essential NCD interventions". Our initial comments: (1) The WHO is clearly medical, focused on health services rather than health promotion. (2) The absence of disease is the goal rather than overall health. (3) Other sectors are expected to be partners but a settings-based approach, essential to these partnerships, is neglected and forgotten. Read more>>

(From the ISHN Member information service)  The release of the WHO status report/global action plan this week represents the efforts of health ministries to address a cluster of physical health diseases. The key facts are not new: "(1) NCD's kill 38 million people each year. (2) Almost 3/4 of deaths (28 million) occur in low- and middle-income countries.(3) Sixteen million deaths occur before the age of 70; 82% of these "premature" deaths occur in low/middle-income countries. (4) Cardiovascular diseases account for most deaths, (17.5 million), followed by cancers (8.2 million), respiratory diseases (4 million), and diabetes (1.5 million). These 4 groups of diseases account for 82% of all NCD deaths. Tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol increase the risk of NCDs. Tobacco accounts for around 6 million deaths every year and is projected to increase to 8 million by 2030. About 3.2 million deaths annually can be attributed to insufficient physical activity. More than half of the 3.3 million annual deaths from harmful drinking are from NCDs In 2010, 1.7 million annual deaths from cardiovascular causes have been attributed to excess salt/s. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them.odium intake.More than 190 countries agreed in 2011 to reduce the avoidable NCD burden in a Global action plan. This plan aims to reduce the number of premature deaths from NCDs by 25% by 2025. In 2015, countries will begin to set national targets and measure progress on the 2010 baselines. The UN General Assembly will convene a third high-level meeting on NCDs in 2018 to take stock of national progress. Read more>>

(From the ISHN Member information service)  Another Canadian youth health survey was released in January 2015. This one is from the province of Manitoba, with data collected in schools in 2012/13, and sponsored by the Manitoba cancer organizations. This is the second time the survey has been done, with a promise of another round in 2016-17. The news story suggests that this provincial survey is unique in Canada but it is not. Several provinces already have similar surveys and Canada participates in the HBSC survey every five years. As well, there are provincial surveys on alcohol/drug use and other federal surveys with youth data. While the survey is a good one and there are questions unique to cancer risks (eg tanning beds), there is something wrong with the picture produced from the survey as well as with the duplication with other surveys. We need more analysis, timely analysis that is more closely correlated with policies and programs. We need regular reports on the status of youth health policies and programs, not just health status or behaviours. We need trends analysis over time (The news story notes that body weights and physical activity have deteriorated slightly since the first survey done in 2003-04 but the report does not include such discussion.). We need reasonable comparisons with similar jurisdictions. We need policy-related discussions. For example, Manitoba combined its health and PE curricula a few years ago...did that have an impact? As well, the province, like most jurisdictions around the world has focused efforts on childhood obesity, with apparently little effect. We are not picking on this survey. It is a good one, with several important questions that ask questions about new items such as transportation to school as part of the physical activity section. But it needs to be part of an overall monitoring and reporting system that is tied to policy-making. (This report on the survey was published on a non-government web site.) It needs to be tied into a national reporting system that can help make the reasonable comparisons between provinces. Canada used to have a regular report that pulled together the various survey results and offered cogent discussion about policies and programs but the funding for that regular report was cut several years ago. A related attempt to coordinate the various national and provincial surveys in that country suffered a similar fate. Canada is not alone in the avoidance of a national monitoring and reporting system. Many countries participate in the Europe-based Health Behaviours of School-age Children (HBSC) survey and a similar WHO Global Student Health Survey (GSHS) but those reports are rarely connected to transparent government policy making. Researchers are usually the ones controlling both the data and the selected analysis. National and state/provincial surveys also need to be part of similar international analysis that permits other useful perspectives and analysis. With the publication of a core set and several thematic of policy/program surveys by several UN agencies under the FRESH school health framework, there is an opportunity to more forward. Can we ensure that future surveys with be part of a systematic monitoring and reporting system in the future?   Read the Manitoba report>>

(From the ISHN Member information service)  An analysis of three school-based initiatives in AIDS/HIV education based on a rights-based approach suggests that we are left with some unfinished business. The article prompting this discussion appears in Issue #1, 2015 of Sex Education: Sexuality, Society and Learning. The authors suggest that "Over the past 25 years, there has been growing investment in concepts of rights in the areas of HIV prevention, care and treatment, including HIV- and AIDS-related education delivered in schools. Despite this increasing commitment to the notion of rights, few efforts appear to have been made to understand the varying conceptions of rights that underpin different kinds of initiatives. Engaging with a multi-disciplinary body of literature on the issue of rights, and through a focus on three rights-informed HIV- and AIDS-related initiatives, this paper seeks to address this gap in the current literature. In so doing, it also examines a central tension within human rights discourse, namely between the construal of rights as shared and universally applicable to all human beings, while being created in and limited by the location in which they were elaborated, as well as by the language used to formulate them. More explicit engagement with the diversity of approaches made possible through a commitment to human rights may facilitate forms of HIV- and AIDS-related education that are more meaningful to young people." Or, in our view, a rights-based approach may create political and social barriers to the expansion and improvement of sex education in schools where the understandings about human rights differ from those articulated by experts and UN agencies. Read more>>

(From the ISHN Member information service)  An article in Issue #3, 2015 of Vaccine reports on a study of the impact of corrective information about side effects and risks associated the flu vaccine may actually harden the decision to not vaccinate among some members of the public. The authors report that "One possible obstacle to greater immunization rates is the false belief that it is possible to contract the flu from the flu vaccine. A nationally representative survey experiment was conducted to assess the extent of this flu vaccine misperception. We find that a substantial portion of the public (43%) believes that the flu vaccine can give you the flu. We also evaluate how an intervention designed to address this concern affects belief in the myth, concerns about flu vaccine safety, and future intent to vaccinate. Corrective information adapted from the Centers for Disease Control and Prevention (CDC) website significantly reduced belief in the myth that the flu vaccine can give you the flu as well as concerns about its safety. However, the correction also significantly reduced intent to vaccinate among respondents with high levels of concern about vaccine side effects – a response that was not observed among those with low levels of concern. This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about vaccines may not be an effective approach to promoting immunization." This finding may support some of the media stories published in January 2015 that suggest that vaccination ferars are connected to a mistrust of public health authorities. Read more>>

 (From the ISHN Member information service)  Two articles in Issue #1, 2015 of Vaccine examine the work of National Advisory Committees on Immunization/Vaccinations in several developed countries in Europe, North America and the Pacific. One of the articles is an editorial that recommends several criteria for improving the effectiveness of such committees. The second article reports on an international study of the functioning of these committees according to criteria such as transparency, scientific validity and committee operations. Both analysis are sensible and scientific, perhaps too much so. In our reading of the criteria for effectiveness, we looked for assessments that suggested these committees were working in the real world, that they were recommending strategies to increase the reach of immunization programs, that they were addressing issues related to vaccine hesitancy, that they devised strategies for communication with parents, that they addressed equity and cultural issues and that they considered how schools can be a partner in almost all vaccination/immunization policies and programs. Perhaps this type of information is available on the various health ministry/committee web sites (the primary source of information for the articles) but these two articles did not report such. It might be time for these national advisory committee members to get out of the laboratory and into the real world of vaccine delivery. Read more>>

 (From the ISHN Member information service)  An article in Issue #49, 2014 of Vaccines reports on a WHO led study on the growing trend among parents around the world. "Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite the availability of vaccination services. Different factors influence vaccine hesitancy and these are context-specific, varying across time and place and with different vaccines. Factors such as complacency, convenience and confidence are involved. Acceptance of vaccines may be decreasing and several explanations for this trend have been proposed." The WHO Strategic Advisory Group of Experts (SAGE) has developed an explanatory model that was tested and found useful in explaining the results of this interview-based study in Immunization Managers in several countries. "Even if there had been reports of vaccine hesitancy in their country, 11 of the 13 IMs considered that vaccine hesitancy was not common and that it did not have a significant impact on vaccine uptake in the routine immunization programmes. IMs from two countries indicated that mass immunization campaigns, rather than routine immunization programmes, were affected by vaccine hesitancy. Factors concerning convenience and ease of access were perceived to be important by nine of the IM's Convenience was a factor for sub-populations which did not use the health services provided and for hard-to-reach populations. However, two IMs stated that vaccine hesitancy was an important issue in their country." When IMs were asked about the percentage of non-vaccinated and under-vaccinated individuals in their country due to lack of confidence in vaccination, only six provided estimates ranging from less than 1% to 20%. Four IMs reported issues of complacency in their countries." Religious beliefs were often a causal factor in vaccine hesitancy (cited by nine IMs).Risk perceptions were identified by seven IMs as causal factors. This included concerns regarding vaccine safety, lack of perceived benefits of vaccination and lack of understanding of the burden of vaccine-preventable diseases. The new, basic understanding of vaccine hesitancy from this first study, which shows an apparent lack of urgency among Immunization Managers, runs counter to the many news stories of returning diseases such as measles in high income countries as well as renewed concerns about infectious diseases in low resource countries. Schools are a convenient site for vaccinations as well as a strong connection for educating parents. School policies about vaccination requirements are also key. More attention and action are warranted. Read more>>

 (From the ISHN Member information service)  An article in Issue #5, 2015 of Vaccine provides an update on the number of countries currently using schools to deliver vaccinations to their populations. The article covers only the delivery of the vaccines and does not discuss the other roles that schools can play in informing parents, educating students, and responding to outbreaks but it underlines the need for a global discussion of the school's role in immunization, development and in national policies/committees." Every year since 1998, UNICEF and WHO collect data through the “WHO-UNICEF Joint Reporting Form (JRF)”, which is completed by Ministries of Health in all Member States [5]. Since 2009, the data includes data on whether a school-based approach is used in a country, what vaccines are being given at what grade and to what age groups, the sex of the children targeted, as well as some additional questions. Countries are asked whether “routine immunization is given to school-aged children using the school as a venue” and should include only “doses that are given as part of the national immunization schedule”, i.e. excluding campaigns". "Of the 195 countries and territories that had been requested to complete the JRF report in 2013 (reporting 2012 data), 189 submitted a JRF form, of which 174 included information on whether a school-based approach was used in their country as of 2012. Of these, 95 answered positively, while 79 said no school-based approach was being used for immunization services". "64% of high income or higher middle income countries reported the existence of a school-based immunization program, against 28% of lower and lower middle income countries". "Most countries provided more than one antigen using a school-based approach, often using combination vaccines. Only 13 countries just gave one antigen, while at the other extreme 3 countries gave 10 different antigens." Read more>>

 (From the ISHN Member information service)   An article in Issue #2, 2015 of the Journal of Interpersonal Violence reports that severe physical abuse affects student educational achievement. Mild physicalabuse and sexual abuse were not correlated with student dropout and eventual years of schooling several years later. "We used data from the Ontario Child Health Study (N = 1,893), a province-wide longitudinal survey. Potential confounding variables (family socio-demographic and parental capacity) and child-level characteristics were assessed in 1983, and child abuse was determined in 2000-2001 based on retrospective self-report. Results showed that PA and SA were associated with several factors indicative of social disadvantage in childhood. Multilevel regression analyses for years of education revealed a significant estimate for severe PA based on the unadjusted model (−0.60 years, 95% CI = [−0.45, −0.76]); estimates for non-severe PA (0.05 years, CI = [−0.15, 0.26]) and SA (−0.25 years, CI = [−0.09, −0.42]) were not significant. In the adjusted full model, the only association to reach significance was between severe PA and reduced years of education (−0.31 years, CI = [−0.18, −0.44]). Multilevel regression analyses for failure to graduate from high school showed significant unadjusted estimates for severe PA (OR = 1.77, 95% CI = [1.21, 2.58]) and non-severe PA (OR = 1.61, CI = [1.01, 2.57]); SA was not associated with this outcome (OR = 1.40, CI = [0.94, 2.07]). In the adjusted full models, there were no significant associations between child abuse variables and failure to graduate. The magnitude of effect of PA on both outcomes was reduced largely by child individual characteristics. Of particular note, severe PA was associated with reduced years of education after accounting for a comprehensive set of potential confounding variables and child characteristics". Read more>>