bluuebunny/crossref_metadata_2025 huggingface dataset:
Innovative methods in teaching public health ethics. The need to adapt to the new times: from challenge to opportunity
Authors: Buron Pust A , Segura A
Published: October 2020

Background

Public Health Ethics (PHE) has been taught first as optional and later as a mandatory subject in the Master of Public Health in Barcelona for about 6 years. During these years, professors have adapted the methodology to make it more attractive and to maximize students' participation and time spent debating and practicing moral reasoning.

Objectives

To showcase 3 different teaching strategies or methods, presenting for each of them: resources required, outcomes so far in terms of satisfaction and exam performance, as well as the pros and cons from the teacher's perspective.

Results

Flipped-classroom strategy: theoretical content is delivered outside the classroom, and the practice into the classroom. Works well but needs incentives for compliance in reading. Versatile debating Methods: from parliamentary debate, to role-playing, online debate, etc. Depending on the Case-study, some work better than others; in the online they practice written deliberation skills, but it is important to set rules. MOOC: Massive Online Open Courses in PHE. Can be used as independent teaching material, it is a great tool to introduce PHE into other PH areas and non-teaching environments.

Conclusions

So far, these methods have proven to increase students' motivation and engagement in Public Health Ethics.

Key messages

Practising reflection and debating skills is an essential part of PHE. Modern teaching strategies, more interactive and online-based, can help maximising the time spent in these activities. Although challenging and time-consuming at first, these methods also increase students' interest in PHE.
Responding to COVID19 in Austria, Germany and Switzerland
Authors: Czyprionka T
Published: October 2020

While it is hard to predict what will have happened by the time of the conference, this round table will be tightly templated and coordinated. Each speaker will briefly address the challenges experienced by that country and the actions taken, and focus on explaining why those actions happened in order to draw comparative lessons about public health politics and governance.
Extrapulmonary tuberculosis among migrants in the EU/EFTA: Implications for policy and practice
Authors: Hayward S E , van der Werf M J , Noori T , Nellums L B , Boccia D , Friedland J S , Hargreaves S
Published: October 2020

Background

The proportion of tuberculosis (TB) cases in the European Union/European Free Trade Association (EU/EFTA) that occur in migrants is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality. To date, there has been no in-depth exploration of extrapulmonary TB in migrants across Europe.

Methods

We analysed 22 years of data from the European Centre for Disease Prevention and Control's European Surveillance System (TESSy) for 32 EU/EFTA countries between 1995 and 2017. We investigated whether the proportion of TB cases that were extrapulmonary varied between migrants and non-migrants, and whether this varied by a) country/region of origin, b) reporting country/region, and c) site of disease.

Results

1,270,896 TB cases were included in the analysis, comprising 326,987 (25.7%) migrants, and 943,909 (74.3%) non-migrants. The proportion of TB that is extrapulmonary is significantly higher in migrants than in non-migrants: 45.2% (n = 147,814) of cases in migrants were extrapulmonary, compared to 21.7% (n = 204,613) in non-migrants (χ2=6.7x104, p < 0.001). A relatively low proportion of extrapulmonary TB was seen in Eastern (17.4%) and Southern (29.6%) Europe compared with Western (35.7%) and Northern (41.8%) Europe, with migrants having a greater proportion of extrapulmonary TB only in Northern/Western Europe. Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary TB, with over half of all cases being extrapulmonary (62.0% and 54.5% respectively).

Conclusions

Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than non-migrants, which has clinical and policy implications for patient detection and management. There is a need to improve clinical awareness of extrapulmonary TB, integrate detection of extrapulmonary TB into latent TB infection screening programmes, and harmonise data collection on migrant status in health systems.

Key messages

Migrants in the EU/EFTA are disproportionately affected by extrapulmonary TB compared to non-migrants. This has clinical and policy implications for diagnosis, screening, and data collection.
Co-design of data collection with participants of the Aberdeen Children of the 1950s cohort study
Authors: Johnston M , Butler J , Clark H , Locock L , Murray A D , Robertson L , Hannaford P , Iversen L , Skea Z , Black C
Published: October 2020

Background

The Aberdeen Children of the 1950s (ACONF) cohort comprises 12,150 people born in Scotland in the 50s. It contains rich early life data, questionnaire data from mid-life and linked electronic health records. Involving participants in designing future data collection is key to ensure research is acceptable and reflects public priorities.

Aim

Gather ACONF members views to inform how to: research healthy ageing, optimise recruitment and maximise participation.

Methods

3 co-design workshops with 30 ACONF members. A discussion was led by a facilitator using guidance questions developed by the study team. Workshops were recorded and transcribed.

Results

Participants viewed healthy ageing as keeping socially and physically active, taking responsibility for oneself and having a positive attitude to ageing. Research priorities were dementia, improvements in the social care system and engaging hard-to-reach groups. Members were keen for future research involvement. Recruitment may be maximised by: more information online, involving participants in recruiting other study members and clarity about potential benefits to themselves or others. It was acceptable to ask their offspring to participate. There were high levels of trust in researchers, but ongoing data protection is vital. Participation may be improved by regular contact (informing members of results, engagement events, phone “apps”). Participants viewed various data collection methods (questionnaires, applications, wearable devices, in-person tests, DNA collection and electronic record linkage) as acceptable.

Conclusions

Participant involvement is a fundamental part of securing a social license for research. Participants were in favour of ongoing research, including recruitment of their children. The workshops highlighted key considerations for future research and data collection.

Key messages

Co-design is vital for highlighting research topics which are important and relevant to the general population. Co-design can highlight strategies for maximising research participation and securing a social license for research.
The fourth decade of life: the age for preventive strategies?
Authors: Cuschieri S
Published: October 2020

Background

Non-communicable diseases (NCDs) have been on the health agenda for decades. As the 2020's decade sets in, most of the set health strategies and targets are ending while new goals are expected. Investigating a European country hub known for its high prevalence of NCDs provides evidence-based data that can be used for these new strategies. The aim was to explore potential NCDs trends and associations that could provide evidence for new preventive strategies and goals.

Methods

Data was obtained from a national representative cross-sectional study through a health examination survey (2014-6). The self-reported data and the results of the examination were used to diagnose participants with type 2 diabetes, dyslipidaemia, hypertension, overweight and obesity. The study population was stratified by ten years and sex for both descriptive and analytic analyses.

Results

The male population was significantly more metabolically unhealthy that the female counterparts across all age groups (p = <0.01). The females had the highest newly diagnosed diabetes prevalence across all age groups. It was observed that type 2 diabetes, dyslipidaemia and hypertension were present as of the 30-39 years group. Conversely, on binary multiple logistic regression analysis, this age group was negatively associated with NCDs even after adjusting for confounders (Diabetes OR:0.06 CI95%:0.02-0.21 p = <0.01; hypertension OR: 0.16 CI 95%: 0.05-0.55 p = <0.01; overweight OR: 0.21 CI 95%: 0.11 - 0.40 p = <0.01).

Conclusions

The fourth decade of life might be the starting point for metabolic dysregulation. Hence, subject to long-term health and economic burdens, with a potential extension of the metabolic impact on their offspring. Although further research is recommended, this study sets the ball rolling whether preventive action including screening for dysglycaemia and dyslipidaemia should be implemented at a population level from a young age.

Key messages

Preventive action should start from fourth decade of life. Targeting the fourth decade of life would also ensure a healthier new generation.
Heart failure hospitalizations in persons with and without diabetes in an Italian region: 2008-2018
Authors: Scampoli P , Di Giovanni P , Cedrone F , D'Addezio M , Di Martino G , Masciarelli M , Meo F , Staniscia T
Published: October 2020

Background

Hospitalization rate for heart failure (HF) is considered a prevention quality indicator and it is used as a tool to evaluate health services quality. This study aims to assess time trends in HF hospitalizations in a region of Southern Italy, focusing on diabetes mellitus as comorbidity.

Methods

Data were collected from hospital discharge records. All patients aged 18 or over hospitalized for HF in Abruzzo between 2008 and 2018 were selected, either with or without a diagnostic code of diabetes. Admissions for cardiac procedures were excluded. For each year, gender- and age-adjusted standardized hospitalization rates were calculated. Predictors of HF admissions were estimated by a multivariable regression model.

Results

Over the study period, 60,737 HF admissions occurred, 34,518 of which among people aged more than 65 (56.8%). A total of 15,424 hospitalizations were performed among diabetic patients (25.4%). The overall age- and gender-adjusted HF hospitalization rate declined substantially from 2008 to 2018 (-12.1%). Diabetes (adjOR 2.48; 95%CI 2.41-2.55), myocardial infarction (adjOR 3.92; 95%CI 3.70-4.14), peripheral vascular disease (adjOR 2.30; 95%CI 2.16-2.44), chronic obstructive pulmonary disease (adjOR 3.97; 95%CI 3.86-4.09) and renal disease (adjOR 5.61; 95%CI 5.44-5.78) were factors associated to an increased risk of HF hospitalization. Although HF admission rates remained higher, a significant reduction was highlighted among diabetic patients (-34.7%). Instead, time trend was nearly stable among persons without diabetes (+2.7%).

Conclusions

This study has shown a decline in HF hospitalization rate over the period considered, particularly among diabetic patients. HF hospitalization may be potentially avoided with good outpatient care. As the causes for HF admissions may include poor quality of care or problems accessing care, it is worthwhile to identify the triggering factors and the potential targets for an early intervention.

Key messages

A reduction of HF admissions was observed only among diabetics and not among people without diabetes. As the HF hospitalizations are potentially preventable, the knowledge of the epidemiology is crucial for management of preventive health care.
Subjective social mobility, quality of life and mental health of asylum seekers/refugees in Germany
Authors: Costa D , Biddle L , Mühling C , Bozorgmehr K
Published: October 2020

Background

Changes in the subjective social status (SSS) of migrants, specifically between the pre- and post-migratory movement, can be a relevant determinant of their mental health condition. This study analyzed the effect of downward subjective social mobility to the mental health of asylum seekers and refugees (ASR) in Germany.

Methods

Through a random sampling procedure, 560 adult ASR (18+ years) were recruited across 58 collective accommodation centers in Germanys' 3rd largest state (2018). SSS was assessed with the MacArthur social ladder (10-rungs), in reference to the participants' position in the country of origin and in Germany. Quality of Life (QoL, measured with EUROHIS-QOL), anxiety (General Anxiety Disorder-2) and depressive symptoms (Patient Health Questionnaire-2), were considered as mental health outcomes. Generalized linear regression models were fitted to measure associations between changes in SSS and each outcome.

Results

A loss of 3 or more steps in SSS from origin to Germany (compared to no-change) was significantly associated with poorer scores in QoL (B, standardized coefficient= -2.679, standard error, se = 1.351, p = 0.047), with more symptoms of depression (B = 1.156, se = 0.389, p = 0.003) and anxiety (B = 0.971, se = 0.432, p = 0.025), in models adjusted for SSS in the country of origin. The strength and direction of associations was unaltered after further adjusting for sex, age, educational level and time since arrival, although the coefficient for QoL was non-significant for those declaring a 3-step downward mobility (B= -2.494, se = 1.351, p = 0.066 for QoL; B = 1.048, se = 0.393, p = 0.008 for depression; and B = 1.006, se = 0.438, p = 0.022 for anxiety).

Discussion

The results suggest that interventions should focus on those experiencing social downward mobility and not only prioritize individuals with low social status. Early integration efforts and intersectoral measures to counter social downward mobility could prevent poor mental health among ASR.

Key messages

We analysed the impact to the quality of life and mental health of asylum seekers and refugees, of a change in subjective social status from country of origin to Germany. Asylum seekers and refugees residing in Germany, who perceived a downward social status mobility following their migration process, are at risk for poorer mental health.
Including public health considerations in trade and investment agreements
Authors: Thow A , Garde A , Mabhala M , Smith R , Kingston P , Manning P , Hunter D , Winters L A , Lincoln P , Parish R
Published: October 2020

There is widespread recognition that trade and investment agreements (TIAs) can affect health services, access to medicines, NCD prevention (particularly related to tobacco, alcohol and unhealthy food) and health systems structures. In addition, these binding international economic agreements can constrain the policy space available for innovative, evidence-based health policymaking. Although TIAs can have positive outcomes for employment and economic growth, these benefits are only likely to accrue when governments are pro-active in implementing complementary policies to mitigate impacts on other sectors and to address potential inequalities arising.

The aim of this panel session is to examine the ways in which TIAs can be designed to achieve economic goals while also protecting public health, and identify complementary policy measures that may be needed as well as strategies for strategic policy engagement. This panel will be hosted by the UK-PRP PETRA Network (Prevention of noncommunicable disease using trade agreements). The UK will be negotiating a range of new TIAs over the coming years, representing a window of opportunity for strategic engagement with policymakers regarding how public health can be protected and promoted within these agreements. There is an emerging global body of evidence regarding how consideration of health can be integrated into TIAs, both textually and through strategic engagement with policymakers before and during the negotiation phase. Experience to date indicates common global challenges and opportunities for health and trade, as well as significant potential for cross country learning regarding trade and health. The panel discussion will use the UK experience as a springboard to address these global issues.
The training of school-doctors in France: ways of improvement, lessons to share
Authors: Godeau E , Chenel S
Published: October 2020

In France protection & prevention of students' health in schools is taken care of by school-doctors, in partnership. They follow a specific training for a year before becoming civil servants in the Ministry of Education. Around 1000 school-doctors are currently in post; 20-30 new school-doctors are trained each year. The training alternates academic sessions & supervised medical work in schools, under the responsibility of experienced mentors. Since 15 years, this training has been revised to improve its relevance in a Public health perspective, mainly by adding a strong health promotion component.

The current organisation aims at (1) individualising the training, capitalising on the knowledge & competencies of trainees, leading to an individual scheme defined with the national coordinators (a school-doctor and a pedagogical engineer) between 8 & 16 weeks of academic sessions given at the French school of Public health; (2) articulating academic contents with pragmatic & professional skills; (3) integrating pedagogical innovations to maximise the development of the 10 competencies identified as core to school-doctors; (4) giving school-doctors a broad Public health perspective, with research and health promotion expertise, while fostering their specific and particular medical practice in the global context of schools.

Each year improvements are implemented to answer the feed-back from trainees and professionals involved in the training. A closer articulation between local heads of school-doctors and the national level of their training has been fostered to improve coherence between academic & technical content while meeting ministerial requirements. The overall involvement & satisfaction of trainees are monitored.

There is still space to improve the training of qualified school-doctors to promote the health of school-students in a Public heath perspective, in a time in France where health inequalities need to be better addressed and where the medical demography is critical.

Key messages

In a time of lack of medical doctors, school-doctors are important public-health actors for children and adolescent, with a very crucial position at the articulation of the health and school systems. The training of school-doctors must meet the challenge to accommodate pedagogical requirements & changes in their practice due to vacant posts while fulfilling ministerial expectations.
Impact of immunization campaign triggered by meningococcal outbreak – Tuscany, 2014-2018
Authors: Bisordi C , Mariotti T , Fornili M , De Vita E , Innocenti F , Baglietto L , Tavoschi L , Lopalco P
Published: October 2020

In 2015-2016, an outbreak of invasive meningococcal disease due to Neisseria meningitidis C/cc11 occurred in Tuscany, Italy, and caused 62 cases. Regional Health Authority launched an immunization campaign using quadrivalent meningococcal conjugate vaccine (MEN) in April 2015. We assessed the impact of meningococcal outbreak on population vaccination coverage, considering a pre-outbreak (2014), outbreak (2015-2016) and a post-outbreak period (2017-2018) for MEN and other vaccinations (HPV and MMR). We included all individuals (>1 year) resident in Tuscany, who received at least one vaccination dose (MEN, HPV, MMR) in the study period. We sourced anonymous data from the regional centralised register on vaccine administered, date, place and dose (for multiple-dose vaccines); birth cohort; city of residence. We analysed vaccine administration by age, time, vaccine type. We modelled MEN vaccination rate as a function of number of cases in the previous month by a quasi-Poisson model (2015-2018), and HPV and MMR vaccination using an interrupted time series analysis (2014-2018).

MEN vaccinations increased significantly in 2015-2016 (average doses/month were 3400 in 2014; 25492 in 2015; 47290 in 2016). MEN immunization coverage increased during the outbreak period, peaking for age class 20-45: from 3,7% in 2014 to 10,7% in 2015 and 20,7% in 2016. MEN vaccination uptake showed a 50% increase (95% CI = 37 to 65%, P < 0.001) in the rate for each new case diagnosed in the previous month. HPV vaccination rate showed statistically significant decreasing trend in before the campaign (-3% per month, 95% CI = -1 to -5%, P = 0.004) disappearing afterwards (0%, 95% CI = -2 to 1%, P = 0.96); with no trend for MMR.

The campaign successfully increased MEN coverage mostly among young adults, although vaccination demand was associated with occurrence of cases. The campaign did not affect routine vaccination programmes, and likely contributed positively to HPV uptake.

Key messages

The immunization campaign triggered by meningococcal outbreak in Tuscany in 2015-2016 successfully increased coverage, mostly among young adults, without affecting routine vaccination programmes. During response campaign triggered by meningitis outbreak in Tuscany in 2015-2016, meningococcal vaccine uptake was influenced by the occurrence of cases.
Gender-related treatment gap in depression among the elderly: a study on 18 European countries
Authors: Roxo L , Perelman J
Published: October 2020

Background

Depression is largely unrecognized and untreated, particularly among men. Help-seeking behaviors are known to differ between genders, yet, these discrepancies are expected to vary along the socioeconomic distribution. This study assesses the gender-related treatment gap for depression and analyzes how it varies with the socioeconomic status.

Methods

We used data from the Wave 6 (2015) of the Survey of Health, Ageing and Retirement in Europe (SHARE) from 56,931 participants aged 50-80 from 18 European countries. Among those depressed (assessed by the EURO-D scale), we modelled previous diagnosis of an emotional problem by a doctor, as proxy for the treatment gap. First, a logistic regression with gender as the explanatory variable was performed, adjusting for age and country. Afterwards, employment and education were factored in and interacted with gender, to assess the differential association of these variables for men and women.

Results

Depression was more prevalent among women (35.5%) than men (19.8%). Among those depressed, women (18.9%) were more likely than men (13.9%) to have been previously diagnosed for an emotional problem (OR = 1.43, 95%CI=1.42-1.43). Compared to men, women had a lower likelihood of diagnosis among homemakers (OR = 0.50, 95%CI=0.49-0.52) and a higher likelihood when unemployed (OR = 2.18, 95%CI=2.16-2.20), employed (OR = 1.10, 95%CI=1.10-1.11), disabled (OR = 1.20, 95%CI=1.19-1.21) with low (OR = 1.26, 95%CI=1.25-1.27) or middle educational level (OR = 1.67, 95%CI=1.66-1.68).

Conclusions

Although depression is more frequent among women, results suggest a larger treatment gap among men. Low- and medium-educated men seem less likely to have been previously diagnosed, as well as those unemployed. Among women, those homemakers are less likely to have been diagnosed with depression.

Key messages

Depressed men are less likely to have been diagnosed, particularly those unemployed and less-educated. Among women, depression diagnosis is less frequent when they are homemakers.
Objective understanding of the front-of-pack nutrition label Nutri-Score by European consumers
Authors: Egnell M , Talati Z , Galan P , Andreeva V , Vandevijvere S , Gombaud M , Dréano-Trécant L , Hercberg S , Pettigrew S , Julia C
Published: October 2020

Background

The effectiveness of Front-of-Pack nutrition Labels (FoPL) may be influenced by national context. In light of the ongoing efforts to harmonize nutrition labelling across Europe, the study aimed to compare the effectiveness of five FoPLs (Health Star Rating system [HSR], Multiple Traffic Lights [MTL], Nutri-Score, Reference Intakes [RIs], Warning symbol) in 12 European consumers.

Methods

In 2018-2019, for three food categories, approximately 1,000 participants per country were asked to select which food they would prefer to purchase between three products with distinct nutritional quality, and then to rank the products nutritional quality. Participants completed these tasks first with no FoPL and then, after randomization to one of the five FoPLs, with a FoPL on food packages. Associations between FoPLs and change in (i) nutritional quality of food choices, and (ii) ability to correctly rank the products nutritional quality were assessed with multivariable logistic regression models.

Results

Compared with the RIs, the Nutri-Score (OR = 3·23[2·75-3·81]; p < 0.0001), followed by the MTL (OR = 1·68[1·42-1·98]; p < 0.0001), was the most effective FoPL in helping participants identify the foods nutritional quality, overall and in each of the 12 countries. Differences between FoPLs regarding food choice modifications were smaller, but the effect of the Nutri-Score was slightly higher in eliciting healthier food choices overall compared with the RIs, followed by the Warning symbol, MTL and HSR.

Conclusions

These findings from an online experiment provide insights on the Nutri-Score's effectiveness in multiple European countries in the context of FoPL harmonization in Europe.

Key messages

The comparison of the effectiveness of front-of-pack labels highlighted the relative performance of various types of labels, the Nutri-Score showing a higher performance than other schemes. The higher performance of the Nutri-Score was identified for objective understanding and to a lesser extent food choices.
Co-designing a virtual community of practice (VCoP) for maternal and child health in Burkina Faso
Authors: Lapierre J , Ouellet M , Goyer-Pétrin G , Gagnon M-P , Dupéré S , Guillaumie L , Abdoulaye A , Côté A , Leblanc N , Uwineza V
Published: October 2020

Background

In Burkina Faso, maternity is a risk. Global Affairs Canada funded the initiative PASME-2 with World University Service of Canada, Laval University and Farm Radio International to improve maternal outcomes. A preventative program was co-developed. Phase 1 included to train the Health Ministry training coordinators. Phase 2 related to the training of nearly 100 health professionals. Phase 3 received funding from Social Sciences and Humanities Research Council in partnership with the Centre for International Cooperation in Health and Development and TIESS, a liaison and transfer expert in Québec, to support local teams towards sustainable practice changes.

Results

On the first objective, to describe the co-development of this living lab are presented. We share our perspective of the co-designing challenges, tools, and solutions. We will demonstrate the VCoP platform and environment. Method. A participative co-design approach, allowed the engagement of several stakeholders in the process. Results. Four workshops were organised. Seventeen maternal and child care health professionals took part in the initial 8-month development phase.

Results

Four steps of the six phases of Gusche innovation design are presented with associated products and results. Implementation challenges, critical decisions, role of face-to-face meetings, technology factors, digital literacy and solutions are presented.

Conclusions

Implementing a technology innovation in low income setting with limited access to the web and to technologies is a challenge. Its advantages are greater: access to evidenced-base care, facilitating professional development, creating a safe space and leading to emerging problem-solving collective solutions. Conceived as a capacitating environment (Sen) and supporting strength-based (Gottlieb) care through partnership, this VCoP becomes a driver of action to maintain preventative health competence and to share experiences and ways of knowing.

Key messages

The digital space crosses the borders and can contribute to human development and expansion of safe, evidenced-based and culturally appropriate professional practices. Working in partnerships, interprofessional and intersectoral, with public and community groups can create synergies that will unfold in greater health equity.
Financial risk protection of individuals with private health insurance
Authors: Blümel M , Achstetter K , Köppen J , Busse R
Published: October 2020

Background

Financial Protection is a key dimension of universal health coverage and health system performance assessment and is also monitored within the framework of the sustainable development goals. Analyses of financial hardship among people who have out-of-pocket (OOP) spending through the use of health services in Germany usually focus solely on households with statutory health insurance due to the peculiarities of private health insurance (PHI) data. This study aims to analyse financial protection among privately insured in Germany.

Methods

A cross-sectional survey was conducted in 2018 with 20,000 privately insured in Germany. The survey comprised questions on household net-income, OOP spending on health, unmet needs, perceived financial burden). Catastrophic expenditure was analysed and defined as share of households with OOP spending greater than 10% of household income. Further results on financial protection and access are based on descriptive analyses.

Results

A total of 3,601 participants (18.0%) completed the survey (58.6 years ± 14.6; 64.6% male). 82.2% of households reported OOP spending, mostly on OTC drugs, deductibles and medical aids. Median OOP spending was €300-499 per year. Average OOP spending as share of household income was 1.3% and 0.6% of households have catastrophic OOP spending. In total, 6.6% of respondents reported unmet needs due to financial barriers, of which 5.3% had no OOP spending. 11.2% of all respondents reported to feel strongly financially burdened by OOP spending with a gap between the lowest (26.2%) and highest income group (9.9%).

Conclusions

PHI insured have comparatively low OOP spending with less than 1% of households having catastrophic expenditures on health. However, 6.2% of respondents reported to forgo care due to financial reasons which supports the assumption that OOP payments can create a barrier to access. Unmet needs and financial burden are higher in lower income groups which raises concerns about equity.

Key messages

Financial protection is good among privately insured in Germany with only few households reporting catastrophic expenditures which indicates a broad and sufficient benefit coverage under PHI. Although out-of-pocket spending is low, privately insured perceive a strong financial burden (particularly in lower income groups) and face financial barriers to access care mirrored in forgone care.
Economic burden of noncommunicable diseases attributable to risk factors in the Russian Federation
Authors: Kontsevaya A , Myrzamatova A , Mukaneeva D , Balanova Y u , Khudyakov M , Drapkina O
Published: October 2020

Aim

to estimate the economic burden of major chronic noncommunicable diseases (NCDs) attributable to risk factors in the Russian Federation in 2016

Material and Methods

The following risk factors were included in the analysis: smoking, high alcohol intake, high salt intake, low intake of fresh vegetables and fruits, consumption of processed red meat, low physical activity, obesity, hypertension, which reliably have a causal relationship with major NCDs: cardiovascular diseases(CVD),type 2 diabetes, chronic obstructive pulmonary disease(COPD), cancer of 10 localizations. The relative risks (RR)of morbidity and mortality from major NCDs associated with risk factors are identified through a literature search. Based on the data on the prevalence of risk factors in the Russian population and RR, the population attributable risk (PAR)was calculated for each analyzed disease. Statistical analysis calculations using descriptive statistics methods were performed in the MSExcel 10.0 program.

Results

The largest burden from the four main NCDs is associated with hypertension - 10.9 billion€, which is equivalent to 1.01% of GDP. The next largest contribution to the burden from NCDs was the burden from obesity 7.6 billion€ 0.7% of GDP, smoking over 5.2 billion €, 0.49% of GDP and the low physical activity 3.4 billion€, 0.32% of GDP. Of all the analyzed risk factors, the least contribution to total costs in connection with NCDs was determined by the burden from high alcohol intake 1.1 billion€, 0.1% of GDP, due to the low prevalence of high alcohol intake in the Russian population.

Conclusions

In this study, for the first time, the assessment of the economic burden of risk factors by the share (contribution) to the morbidity and mortality of main NCDs (CVD, T2DM, COPD and 10 cancer localizations) in the Russian Federation for 2016 was performed. Such the significant economic burden is a strong argument for increasing investments in the prevention and treatment of risk factors of NCDs.

Key messages

In Russia the largest burden from the four main NCDs is associated with hypertension. Such the significant economic burden is a strong argument for increasing investments in the prevention and treatment of risk factors of NCDs.
Impact of financial incentives for primary care to give long acting reversible contraceptive advice
Authors: Ma R , Cecil E , French R , Bottle A , Saxena S
Published: October 2020

Background

Long acting reversible contraceptives (LARC) are cost-effective but uptake remains poor even in high income settings. In 2009/10, a pay-for-performance (P4P) scheme in the United Kingdom was introduced for primary care physicians to offer advice about LARC to women attending for contraceptive care. We examined the equity and impact of this scheme on LARC uptake and abortions

Methods

We examined records of women aged 13 to 54 years registered with a primary care practice in the UK Clinical Practice Research Datalink from 2004/05 to 2013/14. We used interrupted time series analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age, region and deprivation groups, before and after P4P was introduced in 2009/10.

Results

LARC uptake among women of all ages increased immediately after P4P with step change of 5.36 per 1,000 women (95% CI 5.26 to 5.45). Largest increase was in women aged 20 to 24 years (8.40, 8.34 to 8.47). NLHC uptake fell in all women with a step change of -22.9 (-24.5 to -21.2). Among LARC methods, contraceptive injection and implant had the greatest increase after P4P; step changes were 1.68 (1.67 to 1.70) and 1.64 (1.63 to 1.65) respectively. Abortion rates fell across all 12 regions in UK and in all women immediately after P4P with a step change of -2.28 (-2.99 to -1.57). The largest falls occurred in women aged 13 to 19 years (step change -5.04, -7.56 to -2.51) and women from the most deprived group (step change -4.40, -6.89 to -1.91).

Conclusions

Pay-for-performance scheme for primary care physicians to give LARC advice to women attending for contraception was associated with desirable impact and equity of LARC prescriptions and abortion.

LARC uptake increased in women of all ages, especially 13-19 and 20-24 years. Abortion rates fell in all UK regions and age groups, particularly 13-19 and 20-24 years and those from deprived quintile.

Key messages

Pay-for-performance scheme for primary care practitioners to give LARC advice to women attending for contraception was associated with desirable impact and equity of LARC prescriptions and abortion. LARC uptake increased in women of all ages, especially 13-19 and 20-24 years. Abortion rates fell in all UK regions and age groups, particularly 13-19 and 20-24 years and those from deprived quintile.
Out of pocket spending of deceased cancer patients in 5 European countries and Israel
Authors: Tur-Sinai A , Urban D , Bentur N
Published: October 2020

Background

Cancer imposes a substantial economic burden on society, health and social care systems, patients and their families. This study aims to examine the out-of-pocket spending of cancer patients in their last year of life, in six countries with health insurance systems that have a defined benefits package.

Methods

Data from SHARE and SHARE End-of-Life surveys, conducted between 2006 and 2015 among people aged 50+ were analyzed. Family members of deceased persons were interviewed in order to learn about the circumstances of their relative's death.

Results

This study found that out-of-pocket spending of cancer patients during their last year of life, in six developed countries with universal health insurance systems, is 4.5% on average of the total household income at that time. The results also show differences among the countries in out-of-pocket expenditures of the total household income: 2.2% in the Netherlands, 4.3% in Israel, 5% in Germany, 5.1% in Austria, 5.1% in Belgium and 8.2% in Switzerland. Whereas the out-of-pocket spending on nursing home care was 7.8% of the total household income in Switzerland, in the Netherlands and in Israel it was negligible. In contrast, the out-of-pocket spending for home care due to disability surged to 5.6% in Israel and 3.7% in Austria, whereas in other countries it was very low.

Conclusions

This is probably due to the split between the health and the social systems in Israel. The social security administration in Israel is responsible for financing personal care, and the patients have to apply for it themselves. Since the deterioration in functional ability of cancer patients might be quite rapid, many of them pay for professional assistance themselves, until they are approved as eligible for public funds, a process that may last a few weeks. This information is important to health and social policy makers, in order to better adapt the benefits package to the patients' needs.

Key messages

Cancer imposes a substantial economic burden during the last year of life. The economic burden varies across European countries with health insurance systems. Even countries with a universal benefits package take different approaches to prioritizing services and drugs for cancer care and leave some components of care to individual out-of- pocket payment.
Socioeconomic differences in metabolic syndrome remission in adults: mediation of health behaviors
Authors: Hoveling L A , Liefbroer A C , Bültmann U , Smidt N
Published: October 2020

Introduction

Metabolic syndrome (MetS) incidence strongly varies by socioeconomic status (SES). Each SES measure comprises different resources of an individual, including cultural, economic and social resources. To date, no studies have examined the SES - MetS remission relationship. Understanding the role of each SES measure for MetS remission could shed light on resources needed to reverse adverse health conditions. The aim is to longitudinally assess the associations between the SES measures years of education, household equivalent income and occupational prestige and remitted MetS and whether these associations are mediated by health behaviors, including physical activity, smoking, alcohol drinking and diet quality.

Methods

A subsample of the adult Lifelines Cohort Study, including 16,818 participants with MetS at baseline was used. MetS remission was measured at the second assessment (follow-up time 3.8 years) defined according to the NCEP-ATPIII criteria. Direct associations between SES, health behaviors and remitted MetS were estimated using multivariable logistic regression analyses. The mediating percentages of health behaviors explaining the associations between SES and remitted MetS were estimated using the Karlson-Holm-Breen method. Analyses were independent of age, sex, the other SES measures and follow-up time.

Results

At the second assessment MetS remitted for 42.7% of the participants. Education (OR 1.04, 99% CI: 1.02-1.06) and income (OR 1.01, 99% CI: 1.00-1.02) were associated with MetS remission, occupational prestige was not. Health behaviors (11.9%) only explained the association between education and MetS remission. For the explanation of the association between income and MetS remission, health behaviors played no role.

Conclusions

More education years increase MetS remission, mainly because higher educated are more likely to have healthier behaviors. Higher income increases MetS remission, regardless of the health behaviors.

Key messages

Education and income are positively associated with MetS remission. Health behaviors explain a relatively small part of the SES – MetS remission pathway.
Socioeconomic Inequalities in Health Behaviors among Jordanian Adolescents
Authors: Alshammari A , Piko B
Published: October 2020

Background

Health inequalities as a global problem concerns both developed and developing countries. However, levels of inequalities are not the same in different age groups, e.g., during adolescence there are fewer inequalities in morbidity and mortality, while they are more likely to appear in health behaviors. This study aims to test inequality (gender, parental education, and family affluence) in students' health behaviors (dietary habits, hygienic behavior and smoking).

Methods

Using a sample of students (N = 2741, aged 13 - 18 years) from public and private schools in Irbid governorate, Jordan, in the year of 2020, measurements included SES indicators), the Global School-based Student Health Survey and health behaviors (tobacco use, personal hygiene, dietary behavior).

Results

There was a relationship between paternal education and not having enough food at home (p = 0.000), adolescents' brushing their teeth (p = 0.000), eating fruits (p = 0.000), drinking milk (p = 0.000), having fast food (p = 0.000). Results were similar with maternal education, in addition, it was also related to eating vegetables (p = 0.027) and washing their hands before eating (p = 0.005). Smoking was also associated with maternal education (p = 0.009). In terms of family affluence, significant associations can be found between the student's health behavior variables and the self-assessed financial situation in all cases. Finally, females engaged in more healthy dietary and hygienic behaviors and less smoking, while males were more physically active.

Conclusions

Our findings give important evidence for the association between socioeconomic inequalities and health behaviors among Jordanian adolescents. The strongest associations were found with family affluence, while parents' education may have different roles in various types of health behaviors. These findings strengthen the need for policymakers and researchers to pay greater attention to these inequalities.

Key messages

In Jordan, health care should face many challenges in terms of inequalities between different groups of the population according to socioeconomic status. Adolescence is a critical life period when besides biological modifications, there are also psychosocial changes which needs severe adjustment.
No change in life expectancy: the devil is in the detail
Authors: Karanikolos M , Rajan S , Murphy A , McKee M
Published: October 2020

Background

The rate of improvement in life expectancy in high income countries has slowed down over the past few years, and instances where life expectancy is lower than a year before are increasingly common. This paper aims to analyse changes in life expectancy over the last decade to better understand what causes and age groups contribute to the slowdown.

Methods

We use WHO mortality data by age and cause to construct life tables, and we use Arriaga decomposition method to analyse the contribution of specific causes and age groups to changes in life expectancy in Australia, Canada, France, Germany, Netherlands, United Kingdom and the United States of America. We look at the change between 2007-2012 and 2012-2017 (or latest available).

Results

All countries experienced a slowdown in life expectancy in the past 5 years (2012-2017), in comparison to the preceding period. Slowdown in under 65s was particularly pronounced, with younger age groups only contributing minimally (between 0.4 years for males in Germany and -0.4 years for males in the United States) to changes in life expectancy. Among people aged 65 and over, gains ranged between 0.05 years for females in France and 0.6 years for males in the Netherlands. Certain causes of death contributed negatively to change in life expectancy between 2012 and 2017, with notable increases in deaths from accidental poisonings in males (up to -0.09 year in the UK and Canada, and -0.34 in the US) and suicides (up to -0.08 year in Australia and -0.07 in the US).

Conclusions

While recent slowdown in life expectancy gains in high income countries is often attributed to lack of improvement in people of older ages, we show that, beyond this, there are increases in mortality in younger age groups from external causes, that contribute negatively to change in life expectancy in some countries. This pattern is of a particular concern, as deterioration in preventable mortality points to broader worsening of socio-economic climate.

Key messages

Improvements in life expectancy in high income countries slowed down markedly over the past few years, but contributing mortality patterns differ for age groups and causes of death across countries. Persistent increases in preventable mortality from certain external causes in younger age groups in Australia, Canada, US and UK point to broader deterioration of socio-economic climate.
Measuring efficiency of the German health care system from the population perspective
Authors: Köppen J , Achstetter K , Blümel M , Busse R
Published: October 2020

Background

Human and financial resources in health care systems are limited and require efficient use. Efficiency is one of the final goals of the WHO Health Systems Framework but measuring efficiency and finding room for improvement is complex; a rarely used approach is the assessment from the population perspective. This study aims to analyse, if inefficiencies in the German health care system are present and can be identified by the population.

Methods

In 2018, a survey was conducted with a random sample of 20,000 insured persons of a German private health insurance (PHI) company. Three aspects of efficiency were operationalized in the questionnaire: self-reported duplicate tests, prescription of unnecessary health services, and adequacy of insurance premiums. Results are based on descriptive analyses.

Results

In total, 3,601 respondents (age 58.9 ± 14.5; 64.9% male) were included (18.0%) in the analyses. Efficiency was rated as follows: 20% of respondents experienced duplicate tests due to a lack of coordination between physicians. This rate was even higher (38%) among those who perceived (very) poor/fair coordination. Unnecessary services (self-assessed) were prescribed to 22% of all respondents and was 50% among patients who experienced that physicians' consultations and treatments were led by motives other than the patients' wellbeing. A total of 33% rated their premiums as (too) high, 63% as fair and 4% as (very) low with differences according to income, sex and health status.

Conclusions

From a population perspective, the German health care system has the potential to be more efficient e.g. by reducing duplicate tests. Patients with PHI experience unnecessary services and duplicate tests, which put a strain on both, the already limited financial and personnel resources on a macro level, and the level of the individual PHI premium.

Key messages

Patients perceived tests or services as unnecessary, and hence, can detect inefficiencies of a health care system. Efficiency can be improved e.g. by a better coordination of care between health care providers.