Road safety risk factors for non-motorised vehicle users in a Chinese city: an observational study.

OBJECTIVE: The objective of this study is to describe and analyse the prevalence of speeding, helmet use and red-light running among riders of non-motorised vehicles (NMVs) in Shanghai, China, with a focus on electric bikes (ebikes). METHODS: Observational studies were conducted in eight randomly selected locations in Shanghai. Descriptive statistics and a Cox proportional hazard (PH) model were used in the analyses. FINDINGS: A total of 14 828 NMVs were observed in November 2017. At the free flow sites, the average speed was 22.5 km/hour for ebikes and 13.4 km/hour for bicycles. 95.5% of ebikes run above 15 km/hour, the legal speed limit for NMVs in China and 83.8% above 20 km/hour, the maximum design speed for ebikes. Helmet wearing rate was 13.5% for ebike drivers and 9.4% for passengers. Riders of commercial ebikes were nearly three times more likely to wear a helmet than personal ebikes. 22.4% of ebikes were observed to run a red light. The Cox PH model showed that ebikes (vs bicycles), males (vs females), clear weather (vs cloudy, rainy and snowy), helmet users (vs nonusers) are associated with a higher hazard for running a red light. CONCLUSION: To our knowledge, this study is among the first comprehensive evaluation of road user behaviours for NMVs in China. An effective intervention package including regulating ebike production to national standards, strengthening speed enforcement and passing legislation on mandatory helmet use for ebike users may be able to help.

Child Housing Assessment for a Safe Environment (CHASE): a new tool for injury prevention inside the home.

OBJECTIVE: To develop a tool to assess the safety of the home environment that could produce valid measures of a child's risk of suffering an injury. METHODS: Tool development: A four-step process was used to develop the CHASE (Child Housing Assessment for a Safe Environment) tool, including (1) a literature scan, (2) reviewing of existing housing inspection tools, (3) key informants interviews, and (4) reviewing the National Electronic Injury Surveillance System to determine the leading housing elements associated with paediatric injury. Retrospective case-control study to validate the CHASE tool: Recruitment included case (injured) and control (sick but not injured) children and their families from a large, urban paediatric emergency department in Baltimore, Maryland in 2012. Trained inspectors applied both the well-known Home Quality Standard (HQS) and the CHASE tool to each enrollee's home, and we compared scores on individual and summary items between cases and controls. RESULTS: Twenty-five items organised around 12 subdomains were included on the CHASE tool. 71 matched pairs were enrolled and included in the analytic sample. Comparisons between cases and controls revealed statistically significant differences in scores on individual items of the CHASE tool as well as on the overall score, with the cases systematically having worse scores. No differences were found between groups on the HQS measures. CONCLUSION: Programmes conducting housing inspections in the homes of children should consider including the CHASE tool as part of their inspection measures. Future study of the CHASE inspection tool in a prospective trial would help assess its efficacy in preventing injuries and reducing medical costs.

Punching above their weight: a network to understand broader determinants of increasing life expectancy.

BACKGROUND: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. NEW RESEARCH NETWORK: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. CONCLUSION: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Can task-shifting work at scale?: Comparing clinical knowledge of non-physician clinicians to physicians in Nigeria.

BACKGROUND: In contexts with severe physician shortages, the World Health Organization advocates task shifting to cadres with shorter training. To investigate the effects of task shifting at scale in primary health care, we assessed the clinical knowledge of non-physician clinicians versus physicians working in public primary care facilities in Nigeria. METHODS: We assessed 4138 health workers using clinical vignettes of hypothetical patients suffering from illnesses commonly seen in primary care. Facility-level fixed effects models were used to compare health worker knowledge of (i) consultation guidelines, (ii) diagnostic accuracy and (iii) treatment guidelines. RESULTS: Unadjusted averages of overall health worker knowledge were low across all types of worker except medical officers. After adjustment for potential confounding, the differences across all three measures between cadres became small or statistically insignificant. CONCLUSION: Non-physician clinicians can provide the same quality of primary care, for a set of common illnesses, as Medical Officers with similar personal characteristics, but clinical skills across cadres need strengthening.

One Outcome, Many Trends: Understanding National Data Sources for Road Traffic Fatalities in China.

OBJECTIVES: To better understand national data sources and evaluate time trends in road traffic fatalities (RTF) in China. METHODS: We reviewed national sources on RTF data. These included population-based report from the Ministry of Public Security (MPS), sample-based estimates from the Ministry of Health (MOH) and the Disease Surveillance Points System (DSP), as well as model-based estimates from the World Health Organization (WHO), and the Global Burden of Disease Study (GBD). RESULTS: All data sources have limitations in coverage, representativeness or overreliance on model specifications. Despite the discrepancies in methodologies and estimates, all sources indicated an increase in RTF before 2005. Since then, MPS and GBD indicated a decrease, DSP showed plateauing, and MOH and WHO suggested increasing fatalities. However, despite any recent decline, RTF remain high. CONCLUSIONS: The divergent trends in RTF across data sets in China implies a challenge to understanding China's experience with addressing RTF. China needs to reconcile data sources and further improve road safety.

Estimating the influence of maternal height on under-five mortality in Nigeria.

This study uses a nationally representative data sample to assess the effect of maternal height as an intergenerational influence on under-five mortality. Data from the 2003 and 2008 Nigerian Demographic Health Survey (NDHS) (n = 41,005) selecting women aged 15 to 49 yrs whose most recent births were within 5 years (n = 23,568), were analyzed. The outcome measure was under-five mortality. Independent variables included maternal height categorized as > or = 63 inch, 61-62.9 inch, 59.1-60.9 inch, < 59.1 inch. Confounding factors were controlled for. A multivariable logistic regression was used to obtain odds ratio estimates along with their respective confidence interval. After adjusting for confounding factors, we found that each 1 inch increase in maternal height, was associated with a decreased odds of mortality OR 0.98 (95% CI 0.97-0.99). The OR of under-five mortality when comparing women > or = 63 inch versus women < 59.1 inch was 1.13 (95% CI 0.98-1.31). The population attributable fraction of child death due to maternal short stature was 0.36.

Understanding paediatric COVID-19 vaccination during the pandemic: a prospective cohort and a population-based registry study.

Background: Despite the early demonstrated safety and effectiveness of COVID-19 vaccines in children, uptake was slow throughout the pandemic and remains low globally. Understanding vaccine refusal could provide insights to improving vaccine uptake in future pandemics. Methods: In a population-wide registry of all COVID-19 paediatric vaccination appointments, we used interrupted time series analysis to evaluate the impact of public policies. In a population-based cohort of adults, we used population attributable fractions to assess the individual and joint contributions of potential determinants to paediatric COVID-19 vaccination, and used mediation analysis to identify modifiable mediators between political views and paediatric vaccination. Findings: School vaccination requirements were associated with an increase in vaccination appointments by 278.7% (95% CI 85.3-673.9) in adolescents aged 12-17 and 112.8% (27.6-255.0) in children aged 5-11. Government-mandated vaccine pass, required for entry into restaurants, shopping malls and supermarkets, was associated with increased vaccination appointments by 108.7% (26.6-244.0) in adolescents. The following four determinants may explain 82.5% (63.5-100.0) of the reasons why children were unvaccinated: familial political views, vaccine hesitancy for children, mistrust in doctors and academics, and vaccine misconceptions. The influence of political views may be mitigated since 95.9% (76.4-100.0) of its association with vaccine reluctance for adolescents was mediated by modifiable factors such as mistrust in health authorities and low vaccine confidence. Interpretation: School vaccination requirements and vaccine passes were associated with increased vaccine uptake. Clinicians should recognise that factors beyond health, such as political views, can influence paediatric vaccine uptake to a significant extent. Nonetheless, such influences could be mitigated by targeted interventions and public policies. Funding: Hong Kong Jockey Club Charities Trust, Research Grants Council, University Grants Committee, and Health Bureau.

Public health spending, primary care, and perceived risk promoted vaccination against H1N1.

The purpose of this study is to examine factors affecting the intent to vaccinate during the 2009 H1N1 pandemic and to leverage the results to inform public health policy decisions aimed at increasing vaccine uptake during the COVID-19 pandemic. Using the National 2009 H1N1 Flu Survey data and state-level administrative data, we employ logistic regression and mediation models to estimate the association between vaccine uptake and state level public health spending, political ideology, and H1N1 case and death rates as well as a set of individual and household characteristics. We find that higher public health spending can significantly increase the intent to vaccinate, mainly through raising concerns about the pandemic and promoting vaccine relevant doctor patient interactions. We conclude that physicians, especially primary care physicians, should play more important roles in the ongoing vaccination efforts against the COVID-19 virus.

Estimated impact of the 2020 economic downturn on under-5 mortality for 129 countries.

In low- and middle-income countries (LMICs), economic downturns can lead to increased child mortality by affecting dietary, environmental, and care-seeking factors. This study estimates the potential loss of life in children under five years old attributable to economic downturns in 2020. We used a multi-level, mixed effects model to estimate the relationship between gross domestic product (GDP) per capita and under-5 mortality rates (U5MRs) specific to each of 129 LMICs. Public data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020. Country-specific regression coefficients on the relationship between child mortality and GDP were used to estimate the impact on U5MR of reductions in GDP per capita of 5%, 10%, and 15%. A 5% reduction in GDP per capita in 2020 was estimated to cause an additional 282,996 deaths in children under 5 in 2020. At 10% and 15%, recessions led to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. Nearly half of all the potential under-5 lives lost in LMICs were estimated to occur in Sub-Saharan Africa. Because most of these deaths will likely be due to nutrition and environmental factors amenable to intervention, countries should ensure continued investments in food supplementation, growth monitoring, and comprehensive primary health care to mitigate potential burdens.

HPV testing for cervical cancer screening appears more cost-effective than Papanicolau cytology in Mexico.

OBJECTIVE: To determine the incremental costs and effects of different HPV testing strategies, when compared to Papanicolau cytology (Pap), for cervical cancer screening in Mexico. METHODS: A cost-effectiveness analysis (CEA) examined the specific costs and health outcomes associated with (1) no screening; (2) only the Pap test; (3) only self-administered HPV; (4) only clinician administered HPV; and (5) clinician administered HPV plus the Pap test. The costs of self- and clinician-HPV testing, as well as with the Pap test, were identified and quantified. Costs were reported in 2008 US dollars. The health outcome associated with these screening strategies was defined as the number of high-grade cervical intraepithelial neoplasia or cervical cancer cases detected. This CEA was performed using the perspective of the Mexican Institute of Social Security (IMSS) in Morelos, Mexico. RESULTS: Screening women between the ages of 30-80 for cervical cancer using clinical-HPV testing or the combination of clinical-HPV testing, and the Pap is always more cost-effective than using the Pap test alone. CONCLUSIONS: This CEA indicates that HPV testing could be a cost-effective screening alternative for a large health delivery organization such as IMSS. These results may help policy-makers implement HPV testing as part of the IMSS cervical cancer screening program.

Systematic assessment of South Korea's capabilities to control COVID-19.

South Korea's COVID-19 control strategy has been widely emulated. Korea's ability to rapidly achieve disease control in early 2020 without a "Great Lockdown" despite its proximity to China and high population density make its achievement particularly intriguing. This paper helps explain Korea's pre-existing capabilities which enabled the rapid and effective implementation of its COVID-19 control strategies. A systematic assessment across multiple domains demonstrates that South Korea's advantages in controlling its epidemic are owed tremendously to legal and organizational reforms enacted after the MERS outbreak in 2015. Successful implementation of the Korean strategy required more than just a set of actions, measures and policies. It relied on a pre-existing legal framework, financing arrangements, governance and a workforce experienced in outbreak management.

Does social capital increase healthcare financing's projection? Results from the rural household of Uttar Pradesh, India.

In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital - the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control.

Impact of Neighborhood Social and Environmental Resources on Medicaid Spending.

INTRODUCTION: In an era of COVID-19, Black Lives Matter, and unsustainable healthcare spending, efforts to address the root causes of health are urgently needed. Research linking medical spending to variation in neighborhood resources is critical to building the case for increased funding for social conditions. However, few studies link neighborhood factors to medical spending. This study assesses the relationship between neighborhood social and environmental resources and medical spending across the spending distribution. METHODS: Individual-level health outcomes were drawn from a sample of Medicaid enrollees living in Baltimore, Maryland during 2016. A multidimensional index of neighborhood social and environmental resources was created and stratified by tertile (high, medium, and low). Differences were examined in individual-level medical spending associated with living in high-, medium-, or low-resource neighborhoods in unadjusted and adjusted 2-part models and quantile regression models. Analyses were conducted in 2019. RESULTS: Enrollees who live in neighborhoods with low social and environmental resources incur significantly higher spending at the mean and across the distribution of medical spending even after controlling for age, race, sex, and morbidity than those who live in neighborhoods with high social and environmental resources. On average, this spending difference between individuals in low- and those in high-resource neighborhoods is estimated to be $523.60 per person per year. CONCLUSIONS: Living in neighborhoods with low (versus those with high) resources is associated with higher individual-level medical spending across the distribution of medical spending. Findings suggest potential benefits from efforts to address the social and environmental context of neighborhoods in addition to the traditional orientation to addressing individual behavior and risk.

Accelerating policy decisions to adopt haemophilus influenzae type B vaccine: a global, multivariable analysis.

BACKGROUND: Adoption of new and underutilized vaccines by national immunization programs is an essential step towards reducing child mortality. Policy decisions to adopt new vaccines in high mortality countries often lag behind decisions in high-income countries. Using the case of Haemophilus influenzae type b (Hib) vaccine, this paper endeavors to explain these delays through the analysis of country-level economic, epidemiological, programmatic and policy-related factors, as well as the role of the Global Alliance for Vaccines and Immunisation (GAVI Alliance). METHODS AND FINDINGS: Data for 147 countries from 1990 to 2007 were analyzed in accelerated failure time models to identify factors that are associated with the time to decision to adopt Hib vaccine. In multivariable models that control for Gross National Income, region, and burden of Hib disease, the receipt of GAVI support speeded the time to decision by a factor of 0.37 (95% CI 0.18-0.76), or 63%. The presence of two or more neighboring country adopters accelerated decisions to adopt by a factor of 0.50 (95% CI 0.33-0.75). For each 1% increase in vaccine price, decisions to adopt are delayed by a factor of 1.02 (95% CI 1.00-1.04). Global recommendations and local studies were not associated with time to decision. CONCLUSIONS: This study substantiates previous findings related to vaccine price and presents new evidence to suggest that GAVI eligibility is associated with accelerated decisions to adopt Hib vaccine. The influence of neighboring country decisions was also highly significant, suggesting that approaches to support the adoption of new vaccines should consider supply- and demand-side factors.

The estimated magnitude and direct hospital costs of prosthetic joint infections in the United States, 1997 to 2004.

To estimate the number and cost of prosthetic joint infection hospitalizations in civilian US hospitals, we analyzed the 1997 to 2004 National Hospital Discharge Survey for the 996.66 International Classification of Diseases discharge code (infection or inflammatory reaction secondary to internal joint prosthesis). The annual number of such hospitalizations averaged 17 589 from 1997 to 2000 and 29 225 from 2001 to 2004. The annual adjusted diagnostic-related group cost for such infection increased from $195 million to $283 million (1997-2004). The mean diagnostic-related group reimbursement ($9034 per hospitalization) did not vary over time or by comorbidity. The nearly doubled number of prosthetic joint infection-related hospitalizations may have been caused by an increased implant rate, changes in patient population, implant procedures, or causative organisms.

Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

BACKGROUND: Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors. METHODS: Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models. RESULTS: The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP. CONCLUSION: Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.

Results of an RCT in Two Pediatric Emergency Departments to Evaluate the Efficacy of an m-Health Educational App on Car Seat Use.

INTRODUCTION: The growing interest in incorporating prevention into emergency health care make it timely to examine the use of computer technology to efficiently deliver effective education in this setting. STUDY DESIGN: This RCT compared results from an intervention group (n=367) that received child passenger safety information, to an attention-matched control (n=375). A baseline survey and two follow-up surveys at 3 and 6 months were conducted. SETTING/PARTICIPANTS: Data were collected from June 2014 to September 2016 from a sample of parents with children aged 4-7 years recruited from a pediatric emergency department in an East Coast urban area and one in a Midwest semi-rural area. INTERVENTION: A theory-based, stage-tailored educational program, Safety in Seconds v2.0TM, delivered on a mobile app. MAIN OUTCOME MEASURES: Four car seat behaviors: (1) having the correct restraint for the child's age and weight; (2) having the child ride in the backseat all the time; (3) buckling up the child all the time; and (4) having the child's restraint inspected by a child passenger safety technician. RESULTS: At 3 months, adjusting for baseline behaviors and attrition, the odds of reporting the correct behavior by the intervention group relative to the control group was 2.07 (p<0.01) for using the correct car seat; 2.37 (p<0.05) times for having the child ride in the back seat; 1.04 (nonsignificant) for riding buckled up all the time; and 1.99 (p<0.01) times for having the car seat inspected. At 6 months, there were statistically significant effects for reporting use of the correct car seat (OR=1.84, p<0.01) and having the car seat inspected (OR=1.73, p<0.01). CONCLUSIONS: Mobile apps hold promise for reaching large populations with individually tailored child passenger safety education. TRIAL REGISTRATION: Clinical Trial Registration # NCT02345941.