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OBJECTIVES: The two objectives were: (1) to identify, appraise and synthesise research that is relevant to selected UK National Screening Committee (NSC) criteria for a screening programme in relation to partner violence; and (2) to judge whether current evidence fulfils selected NSC criteria for the implementation of screening for partner violence in health-care settings. DATA SOURCES: Fourteen electronic databases from their respective start dates to 31 December 2006. REVIEW METHODS: The review examined seven questions linked to key NSC criteria: QI: What is the prevalence of partner violence against women and what are its health consequences? QII: Are screening tools valid and reliable? QIII: Is screening for partner violence acceptable to women? QIV: Are interventions effective once partner violence is disclosed in a health-care setting? QV: Can mortality or morbidity be reduced following screening? QVI: Is a partner violence screening programme acceptable to health professionals and the public? QVII: Is screening for partner violence cost-effective? Data were selected using different inclusion/exclusion criteria for the seven review questions. The quality of the primary studies was assessed using published appraisal tools. We grouped the findings of the surveys, diagnostic accuracy and intervention studies, and qualitatively analysed differences between outcomes in relation to study quality, setting, populations and, where applicable, the nature of the intervention. We systematically considered each of the selected NSC criteria against the review evidence. RESULTS: The lifetime prevalence of partner violence against women in the general UK population ranged from 13% to 31%, and in clinical populations it was 13-35%. The 1-year prevalence ranged from 4.2% to 6% in the general population. This showed that partner violence against women is a major public health problem and potentially appropriate for screening and intervention. The HITS (Hurts, Insults, Threatens and Screams) scale was the best of several short screening tools for use in health-care settings. Most women patients considered screening acceptable (range 35-99%), although they identified potential harms. The evidence for effectiveness of advocacy is growing, and psychological interventions may be effective, but not necessarily for women identified through screening. No trials of screening programmes measured morbidity and mortality. The acceptability of partner violence screening among health-care professionals ranged from 15% to 95%, and the NSC criterion was not met. There were no cost-effectiveness studies, but a Markov model of a pilot intervention to increase identification of survivors of partner violence in general practice found that such an intervention was potentially cost-effective. CONCLUSIONS: Currently there is insufficient evidence to implement a screening programme for partner violence against women either in health services generally or in specific clinical settings. Recommendations for further research include: trials of system-level interventions and of psychological and advocacy interventions; trials to test theoretically explicit interventions to help understand what works for whom, when and in what contexts; qualitative studies exploring what women want from interventions; cohort studies measuring risk factors, resilience factors and the lifetime trajectory of partner violence; and longitudinal studies measuring the long-term prognosis for survivors of partner violence.

Giving children the best possible start in life is crucial to reduce health disparities.1Fair society, healthy lives. The Marmot Review. UK Department of Health, February.http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-reviewDate: 2010Google Scholar One of the UK Government's efforts to support young children has been to adapt and assess the Family Nurse Partnership (FNP), a programme of prenatal and early childhood home visiting for vulnerable first-time mothers and their children. In The Lancet, Michael Robling and colleagues2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar report on Building Blocks, a multisite trial of the FNP in England. My colleagues and I3Olds DL Prenatal and infancy home visiting by nurses: from randomized trials to community replication.Prev Sci. 2002; 3: 153-172Crossref PubMed Scopus (368) Google Scholar, 4Olds DL Robinson J O'Brien R et al.Home visiting by nurses and by paraprofessionals: a randomized controlled trial.Pediatrics. 2002; 110: 486-496Crossref PubMed Scopus (0) Google Scholar have developed and tested this programme previously in three randomised trials in the USA. We made independent randomised trials a prerequisite for international expansion when serving large populations, because knowing a programme's added value in new contexts is essential for guiding policy and practice. In Robling and colleagues' pragmatic, open, individually randomised, controlled trial,2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar 1645 participants in community midwifery settings at 18 sites in England were randomly assigned to the FNP programme (823 participants received up to 64 structured home visits from early pregnancy until the child's second birthday, delivered by specially recruited and trained family nurses) added to usual care, and 822 received usual care alone. The Building Blocks trial is very well conducted, with objective measures, acceptable rates of completed assessments for most outcomes, and rigorous adherence to its statistical analysis plan; this strengthens the conclusion that FNP had no effects compared with usual care on the study's primary outcomes: prenatal cigarette smoking at the end of pregnancy (304 [56%] of 547 participants with FNP vs 306 [56%] of 545 with usual care), subsequent pregnancies (426 [66%] of 643 with FNP vs 427 [66%] of 646 with usual care), birthweight (mean birthweight 3217·4 g [SD 618·0] for 742 children with FNP vs 3197·5 g [SD 581·5] for 768 children with usual care), or at least one child emergency encounter or hospital admission at an accident and emergency department (587 [81%] of 725 children with FNP vs 577 [77%] of 753 children with usual care).2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar The study's design would have been strengthened, however, had it been guided more completely by findings from previous trials.3Olds DL Prenatal and infancy home visiting by nurses: from randomized trials to community replication.Prev Sci. 2002; 3: 153-172Crossref PubMed Scopus (368) Google Scholar, 4Olds DL Robinson J O'Brien R et al.Home visiting by nurses and by paraprofessionals: a randomized controlled trial.Pediatrics. 2002; 110: 486-496Crossref PubMed Scopus (0) Google Scholar, 5Olds D Kitzman H Cole R et al.Effects of nurse home visiting on maternal life-course and child development: age-six follow-up of a randomized trial.Pediatrics. 2004; 114: 1550-1559Crossref PubMed Scopus (0) Google Scholar Moreover, its results need to be understood in the context of usual care after FNP was added to local services. I raise these issues to encourage a deeper conversation within scientific and policy communities about how best to use scarce research resources aimed at improving the early health and development of vulnerable populations. As Robling and colleagues note, US trials identified that programme benefits, such as mothers' use of cash-assistance welfare, timing of subsequent pregnancies, verified reports of child maltreatment, injuries and ingestions, and language and cognitive development, were most pronounced in families living in concentrated disadvantage and, for children, those born to mothers who had few psychological resources to cope with adversity.3Olds DL Prenatal and infancy home visiting by nurses: from randomized trials to community replication.Prev Sci. 2002; 3: 153-172Crossref PubMed Scopus (368) Google Scholar, 4Olds DL Robinson J O'Brien R et al.Home visiting by nurses and by paraprofessionals: a randomized controlled trial.Pediatrics. 2002; 110: 486-496Crossref PubMed Scopus (0) Google Scholar, 5Olds D Kitzman H Cole R et al.Effects of nurse home visiting on maternal life-course and child development: age-six follow-up of a randomized trial.Pediatrics. 2004; 114: 1550-1559Crossref PubMed Scopus (0) Google Scholar The UK FNP has focused on young mothers (<20 years of age) because their children are at risk of compromised development,6Chittleborough CR Lawlor DA Lynch JW Young maternal age and poor child development: predictive validity from a birth cohort.Pediatrics. 2011; 127: e1436-e1444Crossref PubMed Scopus (39) Google Scholar and maternal age makes it easy to identify who qualifies.7Hall D Hall S The “Family-Nurse Partnership”: developing an instrument for identification, assessment and recruitment of clients. Departments for Children, Schools and Families, London2007Crossref Scopus (7) Google Scholar However, young mothers vary substantially in the extent to which they have overlapping challenges, such as financial difficulties, depression, and substance misuse.6Chittleborough CR Lawlor DA Lynch JW Young maternal age and poor child development: predictive validity from a birth cohort.Pediatrics. 2011; 127: e1436-e1444Crossref PubMed Scopus (39) Google Scholar Positive FNP effects identified in a Dutch trial8Mejdoubi J van den Heijkant SCCM van Leerdam FJM Heymans MW Crijnen A Hirasing RA The Effect of VoorZorg, the Dutch Nurse-Family Partnership, on child maltreatment and development: a randomized controlled trial.PLoS One. 2015; 10: 1-14Crossref Scopus (0) Google Scholar, 9Mejdoubi J van den Heijkant SCCM van Leerdam FJM Heymans MW Hirasing RA Crijnen AM Effect of nurse-home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: a randomized controlled trial.PLoS One. 2013; 8: e78185Crossref PubMed Scopus (0) Google Scholar of 460 disadvantaged women on outcomes such as child maltreatment, children's internalising behavioural problems, and intimate partner violence might be attributed, at least partly, to its serving highly vulnerable mothers, irrespective of their age. Robling and colleagues' trial examined a set of possible moderators of FNP effects, but it was not designed to estimate effects with those most vulnerable. Moreover, we need to consider what usual care was in Robling and colleagues' study.2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar How did efforts of teenage pregnancy midwives and health visitors affect estimates of FNP's added value? The usual-care group, for instance, received a mean of 16·25 (SD 12·15) visits by health visitors—a number probably even higher in those at risk. In view of the fact that health visitors in this trial were informed of mothers' service assignments and directed not to visit families in FNP, the 8·6 (SD 13·74) mean number of health-visitor encounters reported by mothers in FNP must be interpreted with caution. FNP records show a mean of 39·28 (SD 15·19) FNP visits completed during pregnancy through to the age of 2 years; this represents excellent maternal engagement and is probably more than enough to help low-risk mothers.10Holland ML Xia Y Kitzman HJ Dozier AM Olds DL Patterns of visit attendance in the Nurse-Family Partnership program.Am J Public Health Res. 2014; 104: e58-e65Crossref Scopus (0) Google Scholar Additionally, FNP and usual-care effects on prenatal smoking should be placed in the context of other smoking interventions. As noted in the supplementary materials,2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar women in FNP identified as smokers at registration quit at a rate of 17% (49 of 293) compared with 17% (49 of 297) of those in usual care. Although smoking cessation as an outcome overlooks women identified as smokers at the end of pregnancy who were not classified as smokers at registration, it allows us to put the prenatal smoking effects in the trial into context.11Chamberlain C O'Mara-Eves A Oliver S et al.Psychosocial interventions for supporting women to stop smoking in pregnancy.Cochrane Database Syst Rev. 2013; 10: 1-293Google Scholar These cessation rates are much larger than those identified for most prenatal counselling and education interventions for women who smoked at baseline, and in which cessation is biochemically validated (ie, 9–11%, calculated from studies reported in a review of the scientific literature).11Chamberlain C O'Mara-Eves A Oliver S et al.Psychosocial interventions for supporting women to stop smoking in pregnancy.Cochrane Database Syst Rev. 2013; 10: 1-293Google Scholar Thus, both usual care and FNP were comparatively successful, notwithstanding how much more needs to be done to reduce prenatal cigarette smoking. By contrast, neither FNP nor usual care prevented subsequent pregnancy within 24 months after delivery of the first child (66% in both groups). These high rates make me wonder whether this outcome has the same functional meaning in this sample as it does elsewhere.12Conde-Agudelo A Rosas-Bermúdez A Kafury-Goeta A Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.JAMA. 2006; 295: 1809-1823Crossref PubMed Scopus (768) Google Scholar The two primary child outcomes selected for Robling and colleagues' trial2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar are not outcomes that FNP claims to affect. There were no previous replicated effects on birthweight or children's accident and emergency department encounters as operationalised in this trial. It is noteworthy that this accident and emergency outcome combines all emergency encounters and hospital admissions into a single yes or no variable. This categorisation does not distinguish, for example, between a concerned parent taking a child with a possible ear infection to accident and emergency when GP care is unavailable, and a comatose child admitted for abusive head trauma. The higher rate of an accident and emergency outcome encounter in the FNP group (81% vs 77%) might represent heightened parental concern and raises questions about this variable's meaning. Two child outcomes of clear public health importance affected in previous trials were not selected as primary outcomes. The first is language or cognitive development, which was measured objectively in earlier trials.3Olds DL Prenatal and infancy home visiting by nurses: from randomized trials to community replication.Prev Sci. 2002; 3: 153-172Crossref PubMed Scopus (368) Google Scholar, 4Olds DL Robinson J O'Brien R et al.Home visiting by nurses and by paraprofessionals: a randomized controlled trial.Pediatrics. 2002; 110: 486-496Crossref PubMed Scopus (0) Google Scholar, 5Olds D Kitzman H Cole R et al.Effects of nurse home visiting on maternal life-course and child development: age-six follow-up of a randomized trial.Pediatrics. 2004; 114: 1550-1559Crossref PubMed Scopus (0) Google Scholar Robling and colleagues' study2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar would have been strengthened had its designers identified language as a primary outcome and measured it directly. In view of previous replicated effects, the significant intervention–control differences in maternally reported language development (and language and cognitive development concerns) in this trial are promising: at the age of 24 months, children in the FNP group had mean Early Language Milestone percentile values of 60·8 (SD 31·4) versus 55·7 (SD 31·4) for children in the usual-care group; at age 18 months, language development concerns (children not meeting milestones) were present for 84 (17%) of 490 in the FNP group versus 110 (24%) of 455 for those in usual care; and at 24 months, cognitive development concerns were present for 46 (8%) of 569 children in the FNP group versus 66 (13%) of 522 for those in usual care. Both children in FNP and usual care exceeded the median normative values for age-matched children assessed with the Early Language Milestone; both groups were faring better than most children of their age. The second outcome of importance is serious injury, often an indication of maltreatment in young children. Although more safeguarding was reported in FNP than in usual-care families, this is consistent with previous findings,13Olds D Henderson C Kitzman H Cole R Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment.Pediatrics. 1995; 95: 365-372PubMed Google Scholar and probably represents FNP nurses' efforts to ensure children's protection. In view of previous programme impact on maltreatment and length of hospital stay for injuries,3Olds DL Prenatal and infancy home visiting by nurses: from randomized trials to community replication.Prev Sci. 2002; 3: 153-172Crossref PubMed Scopus (368) Google Scholar a case can be made for examining serious injuries in such trials—an outcome much more consistent with previous effects. Those responsible for delivering FNP in the UK must now determine next steps. Continued assessment is essential as increased effort is focused on mothers who need FNP the most, and intensified support is given to nurses tackling challenging behaviour, such as maternal smoking and pregnancy planning. The results of Robling and colleagues' trial2Robling M Bekkers M-J Bell K et al.Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial.Lancet. 2015; (published online Oct 14.)http://dx.doi.org/10.1016/S0140-6736(15)00392-XPubMed Google Scholar underscore why we cannot simply disseminate programmes without assessing them, and why, to accelerate construction of a solid early-intervention evidence base, we need to ensure that results and insights from previous studies are integrated thoroughly into the designs of new ones. I, with colleagues, founded the Nurse-Family Partnership (NFP; also known as FNP). The Prevention Research Center for Family and Child Health (PRC), which I direct at the University of Colorado School of Medicine, USA, receives licensing fees and travel expenses from governments and entities outside the USA linked to its implementation. My institution has received fees from the UK Department of Health; the British Columbia Department of Health, Canada; Simon Fraser University, Canada; the City of Hamilton, Canada; and agencies in Australia, Norway, Bulgaria, the Netherlands, Scotland, and Northern Ireland. I also have received research funding from National Institute of Justice (public funding), the National Institute on Drug Abuse (public funding), the John and Marcie Fox Foundation, and Pyramid Peak Foundation. In the USA, NFP is replicated by the NFP National Service Office, which provides funding to the PRC for research on improving NFP and its implementation. I have received compensation for consulting with the following organisations: the Coalition for Evidence-Based Policy, the Urban-Child Institute, and the Department of Psychiatry and Behavioral Sciences, Northwestern University. Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trialAdding FNP to the usually provided health and social care provided no additional short-term benefit to our primary outcomes. Programme continuation is not justified on the basis of available evidence, but could be reconsidered should supportive longer-term evidence emerge. Full-Text PDF Open Access

BACKGROUND: The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. METHODS: We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. RESULTS: Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. CONCLUSIONS: Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

INTRODUCTION: The effects of healthcare-related inequalities are most evident in low-resource settings. Such settings are often not explicitly defined, and umbrella terms which are easier to operationalise, such as 'low-to-middle-income countries' or 'developing countries', are often used. Without a deeper understanding of context, such proxies are pregnant with assumptions, insinuate homogeneity that is unsupported and hamper knowledge translation between settings. METHODS: A systematic scoping review was undertaken to start unravelling the term 'low-resource setting'. PubMed, Africa-Wide, Web of Science and Scopus were searched (24 June 2019), dating back ≤5 years, using terms related to 'low-resource setting' and 'rehabilitation'. Rehabilitation was chosen as a methodological vehicle due to its holistic nature (eg, multidisciplinary, relevance across burden of disease, and throughout continuum of care) and expertise within the research team. Qualitative content analysis through an inductive approach was used. RESULTS: A total of 410 codes were derived from 48 unique articles within the field of rehabilitation, grouped into 63 content categories, and identified nine major themes relating to the term 'low-resource setting'. Themes that emerged relate to (1) financial pressure, (2) suboptimal healthcare service delivery, (3) underdeveloped infrastructure, (4) paucity of knowledge, (5) research challenges and considerations, (6) restricted social resources, (7) geographical and environmental factors, (8) human resource limitations and (9) the influence of beliefs and practices. CONCLUSION: The emerging themes may assist with (1) the groundwork needed to unravel 'low-resource settings' in health-related research, (2) moving away from assumptive umbrella terms like 'low-to-middle-income countries' or 'low/middle-income countries' and (3) promoting effective knowledge transfer between settings.

This paper reports the results of a critical review of empirical evidence relating to the aetiology of child sexual abuse (CSA) published over the last 15 years. The current review found that the psychology, criminal history and prior victimisation of the perpetrator and the gender, disability status, sexuality and family circumstances of the victim are important risk factors for CSA. Offence characteristics such as the offender‐victim relationship, modus operandi of the perpetrator and absence of a capable guardian are also found to be important markers of risk. We make suggestions for future research frameworks and designs, and we discuss the implications of the evidence for future primary prevention initiatives, practice and policy. We use this evidence to make recommendations for the development of child maltreatment theory more generally. ‘A critical review of empirical evidence relating to the aetiology of child sexual abuse published over the last 15 years’ Key Practitioner Messages Understanding of CSA perpetration is not well advanced and it is likely to be far more complex than currently thought. Intersectionality exists between cultural and sociocultural influences for CSA. The causes and consequences of CSA are both different to and the same as other forms of maltreatment, but we do not yet have sufficiently nuanced evidence to say how much these diverge and converge. The evidence is mixed and difficult to interpret regarding offenders' own childhood experiences of CSA.

Child maltreatment (CM) in foster care settings (i.e., institutional abuse, IA) is known to have negative effects on adult survivor's mental health. This study examines and compares the extent of CM (physical, emotional, and sexual abuse; physical and emotional neglect) and lifetime traumatization with regard to current adult mental health in a group of survivors of IA and a comparison group from the community. Participants in the foster care group (n = 220) were adult survivors of IA in Viennese foster care institutions, the comparison group (n = 234) consisted of persons from the Viennese population. The comparison group included persons who were exposed to CM within their families. Participants completed the Childhood Trauma Questionnaire, the Life Events Checklist for DSM-5, the PTSD Checklist for DSM-5, the International Trauma Questionnaire for ICD-11, and the Brief Symptom Inventory-18 and completed a structured clinical interview. Participants in the foster care group showed higher scores in all types of CM than the comparison group and 57.7% reported exposure to all types of CM. The foster care group had significantly higher prevalence rates in almost all mental disorders including personality disorders and suffered from higher symptom distress in all dimensional measures of psychopathology including depression, anxiety, somatization, dissociation, and the symptom dimensions of PTSD. In both groups, adult life events and some but not all forms of CM predicted PTSD and adult life events partly mediated the association of PTSD and CM. Explanations for the severe consequences of CM and IA are discussed.

Osteoporosis imposes a tremendous burden on Australia: 1.2 million Australians have osteoporosis and 6.3 million have osteopenia. In the 2007–08 financial year, 82 000 Australians suffered fragility fractures, of which > 17 000 were hip fractures. In the 2000–01 financial year, direct costs were estimated at $1.9 billion per year and an additional $5.6 billion on indirect costs. Osteoporosis was designated a National Health Priority Area in 2002; however, implementation of national plans has not yet matched the rhetoric in terms of urgency. Building healthy bones throughout life, the Osteoporosis Australia strategy to prevent osteoporosis throughout the life cycle, presents an evidence-informed set of recommendations for consumers, health care professionals and policymakers. The strategy was adopted by consensus at the Osteoporosis Australia Summit in Sydney, 20 October 2011. Primary objectives throughout the life cycle are: to maximise peak bone mass during childhood and adolescence to prevent premature bone loss and improve or maintain muscle mass, strength and functional capacity in healthy adults to prevent and treat osteoporosis in order to minimise the risk of suffering fragility fractures, and reduce falls risk, in older people. The recommendations focus on three affordable and important interventions — to ensure people have adequate calcium intake, vitamin D levels and appropriate physical activity throughout their lives. Recommendations relevant to all stages of life include: daily dietary calcium intakes should be consistent with Australian and New Zealand guidelines serum levels of vitamin D in the general population should be above 50nmol/L in winter or early spring for optimal bone health regular weight-bearing physical activity, muscle strengthening exercises and challenging balance/mobility activities should be conducted in a safe environment.