Predictors of Change in Vaccination Decisions Among the Vaccine Hesitant: Examining the Roles of Age and Intolerance of Uncertainty.

BACKGROUND: Vaccine hesitancy and resistance pose significant threats to controlling pandemics and preventing infectious diseases. In a group of individuals unvaccinated against the disease caused by the SARS-CoV-2 coronavirus (COVID-19), we investigated how age, intolerance of uncertainty (IU), and their interaction affected the likelihood of having changed one's vaccination decision a year later. We hypothesized that higher IU would increase the likelihood of becoming vaccinated, particularly among individuals of younger age. We predicted that this effect would remain significant, even after controlling for delay discounting and trust in science. PURPOSE: The goal of this research was to understand the factors influencing changes in vaccination decisions among the vaccine hesitant. METHODS: In a larger longitudinal study, ~7,500 participants from Prolific.co completed demographic and vaccination status questions, a delay discounting task, and the Intolerance of Uncertainty Scale in June-August 2021. Approximately 3,200 participants completed a follow-up survey in July-August 2022, answering questions about vaccination status, reasons for vaccination decision, and trust in science. We analyzed data from 251 participants who initially had no intention of getting vaccinated and completed the follow-up survey; 38% reported becoming vaccinated in the intervening year. RESULTS: Data were analyzed using multilevel logistic regression. Over and above other factors related to vaccination decisions (delay discounting, trust in science), younger participants were more likely to change their decision and become vaccinated a year later, especially if they had higher IU, confirming our predictions. Primary reasons for becoming vaccinated were necessity and seeking protection against the virus. CONCLUSIONS: These findings highlight the complex interplay between age, uncertainty, and vaccination decisions, and inform health policies by suggesting the need for tailoring interventions to specific concerns in different age groups.

Vaccine hesitancy and resistance pose significant threats to controlling pandemics and preventing infectious diseases. It is important to understand the factors that influence whether or not unvaccinated individuals change their mind and get vaccinated. We investigated how age and one's intolerance of uncertainty predicted the likelihood of changing one's mind about getting a COVID-19 vaccination in a group of 251 unvaccinated participants. In mid-2021, these individuals indicated they had no intention to get vaccinated; by mid-2022, 38% of them reported that they had been vaccinated. Over and above other factors known to be related to vaccination decisions (delay discounting and trust in science), we found that younger participants were more likely to have changed their minds and become vaccinated a year later, especially if they were less tolerant of uncertainty. Of the reasons provided by participants for having been vaccinated, necessity and seeking protection against the virus were the most common. These findings highlight the complex interplay between age, uncertainty, and vaccination decisions. Importantly, these findings will inform health policies, suggesting the need for tailoring interventions to specific concerns in different age groups.

Bridging the Gap in Harm Reduction Using Mobile Overdose Response Services (MORS) in the Context of the COVID-19 Pandemic: A Qualitative Study.

The COVID-19 pandemic introduced additional health challenges for people who use substances (PWUS) amid the overdose crisis. Numerous harm reduction services, including supervised consumption sites (SCS) across Canada, faced shutdowns and reduced operating capacity in order to comply with public health measures. Mobile Overdose Response Services (MORS) are novel overdose prevention technologies that allow those who are unable to access alternative means of harm reduction to consume substances under the virtual supervision of a trained operator. Here, we examine the role of MORS in the context of the COVID-19 pandemic. A total of 59 semi-structured interviews were conducted with the following key interest groups: PWUS, healthcare providers, harm reduction workers, MORS operators, and the general public. Inductive thematic analysis informed by grounded theory was used to identify major themes pertaining to the perception of MORS. As the pandemic shifted the public focus away from harm reduction, many participants viewed MORS as an acceptable strategy to reduce the harms associated with solitary substance and alleviate the sense of isolation driven by social distancing measures. While the pandemic may have increased the utility of MORS, concerns surrounding personal privacy and confidentiality remained. Overall, MORS were perceived as a useful adjunct service to address the unmet needs PWUS during the pandemic and beyond.

The association between neighbourhood walkability and blood lipids: a Canadian population study.

We examined the association between walkability and blood lipids in a nationally representative sample of 29,649 participants aged 3-79 years who participated in the Canadian Health Measures Survey (CHMS) cycles 1 to 6. We focused on seven lipid biomarkers: apolipoprotein A (Apo A), apolipoprotein B (Apo B), triglycerides (TG), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), total cholesterol (TC), and TC/HDL. Cross-sectional associations were analyzed using generalized linear mixed models incorporating survey-specific sampling weights. An increase in the Canadian Active Living Environments Index, a measure of neighborhood walkability, equivalent to the magnitude of its interquartile range (IQR) was associated with the following percentage (95% confidence intervals (CI)) changes in lipids: decreased TG, -2.85 (-4.77, -0.93) and TC/HDL, -1.68 (-2.80, -0.56), and increased HDL, 1.68 (0.93, 2.42). Significant effects were largely restricted to adults (aged 17 to 79). In the younger age group there were no significant associations between walkability and lipids in the fully adjusted model. Significant associations were more frequently seen in females than males. For females, fully adjusted significant inverse associations were observed for TG, LDL, and TC/HDL, and there were positive associations with HDL and Apo A. Canadians living in more walkable neighborhoods have more favorable lipid profiles, suggesting that the built environment has the potential to influence the risk profile for cardiovascular health, especially among adults and females.

Self-reported chronic conditions and COVID-19 public health measures among Canadian adults: an analysis of the Canadian longitudinal study on aging.

OBJECTIVES: During the COVID-19 pandemic, public health measures were used to reduce the spread of COVID-19; it is unknown whether people with chronic conditions differentially adhered to public health measures. The objectives of this study were to evaluate the association between chronic conditions and adherence and to explore effect modification by sex, age, and income. STUDY DESIGN: An analysis of data from the Canadian Longitudinal Study on Aging COVID-19 Questionnaires (from April to September 2020) was conducted among middle-aged and older adults aged 50-96 years (n = 28,086). METHODS: Self-reported chronic conditions included lung disease, diabetes, heart disease, cancer, obesity, anxiety, and depression. Multinomial logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between chronic conditions and low, medium, and high levels of adherence. Effect modification was evaluated using statistical interaction and stratification. RESULTS: Most people (n = 17,435; 62%) had at least one chronic condition, and 2866 (10%) had three to seven chronic conditions. Among those with high adherence to public health measures, 69% had one or more chronic condition (n = 2266). Having three to seven chronic conditions, compared with none, was associated with higher adherence to public health measures (OR: 2.14; 95% CI: 1.12-1.42). Higher adherence was also noted across chronic conditions, for example, those with diabetes had higher adherence (OR: 1.72; 95% CI: 1.53-1.93). There was limited evidence of effect modification by sex, age, or income. CONCLUSIONS: Canadians with chronic conditions were more likely to adhere to public health measures; however, future research is needed to understand whether adherence helped to prevent adverse COVID-19 outcomes and if adherence had unintended consequences.

Harmonizing the assessment of allostatic load across cycles of the Canadian Health Measures Survey: Variable selection and calculation method.

Background: The availability of measures to operationalize allostatic load - the cumulative toll on the body of responding to stressor demands - in population health surveys may differ across years or surveys, hampering analyses on the entire sampled population. Here, impacts of variable selection and calculation method were evaluated to generate an allostatic load index applicable across all cycles of the Canadian Health Measures Survey (CHMS). Methods: Data from CHMS cycles 1 to 4 were used to compare allostatic load scores when replacing the most prevalent risk factor, waist-to-hip ratio - available in cycles 1 to 4 but not 5 and 6 - with body mass index (BMI), waist circumference, waist circumference within BMI groups (classified as normal, overweight, or obese), or waist-to-height ratio. Indexes were generated using clinical or sex-specific empirically defined risk thresholds and as count-based or continuous scores. Logistic regression models that included age and sex were used to relate each potential index to socioeconomic indicators (educational attainment, household income). Results: Of the variables assessed, waist-to-height ratio and waist circumference were closest to waist-to-hip ratio according to an individual's percentile ranking and in classifying "at risk" using either clinical or empirically defined cut-offs. Allostatic load profiles generated using waist-to-height ratios most closely resembled profiles constructed using waist-to-hip ratios. Sex-dependent associations with educational attainment and household income were maintained across constructs whether indexes were count-based or continuous. Interpretation: Allostatic load profiles and associations with socioeconomic indicators were robust to variable substitution and method of calculation, supporting the use of a harmonized index across survey cycles to assess the cumulative toll on health of stressor exposure.

Understanding the Experiences of COVID-19 Public Health Measures and Well-Being: A Qualitative Study Among Older Adults in Quebec, Canada.

This interpretative descriptive study explores how public health measures implemented during the first wave of the COVID-19 pandemic in Quebec, Canada, affected the well-being of older adults. Twenty-six participants aged 60-81 took photographs to depict how COVID-19 public health measures affected their well-being and were invited to discuss their photographs in virtual focus groups. Data were analyzed using thematic analysis. The impacts of health measures on the well-being of participants were framed according to three overarching themes. First, participants endured an intensification of ageism, feeling diminished and excluded from their social spheres. Second, they faced a burden of loneliness due to the loss of connections with their communities, particularly for those who were single and without children. Third, participants highlighted navigating a degradation of social cohesion. This manifested through tensions and distrust in both the public and private spheres, as well as acts of resistance in response to rules deemed unjust. While public health measures were essential to prevent onward transmission of COVID-19 and mortality, they negatively impacted older adults' self-image, loneliness, and trust in society. This study argues for a rethinking of public health norms specific to older adults to address potential sources of inequality. In particular, a greater emphasis is needed on social connectedness and addressing the unique needs of older adults during pandemics.

[Infection epidemiological effects of school closures during the second COVID-19 pandemic wave-an exemplary analysis within a lower Bavarian region]. / Infektionsepidemiologische Effekte von Schulschließungen während der zweiten COVID-19-Pandemiewelle ­ Eine exemplarische Analyse innerhalb einer niederbayerischen Region.

BACKGROUND: The rapid global spread of the SARS-CoV­2 virus during the COVID-19 pandemic led to widespread non-pharmaceutical interventions, such as school closures, to curb infections. This study investigates the influence of school closures on the number of new infections to reduce the existing knowledge gap in this area. METHODS: The effect of school closures starting on 16 December 2020, was quantified using COVID-19 infection data from the district and city of Landshut in Bavaria between November 2020 and January 2021. An interrupted time series (ITS) analysis was performed to analyze daily new infections among 6-18 year olds and the entire population in the region before and after the school closures using a negative binomial regression model. RESULTS: The analysis showed that the trend of daily new COVID-19 infections among 6-18 year olds significantly decreased after the school closures (incidence rate ratio (IRR) 0.93; 95% confidence interval (CI): 0.89-0.96; p < 0.001). This was also true for the entire study population (IRR 0.95; 95% CI: 0.93-0.97; p < 0.001). DISCUSSION: In the context of various concurrent measures to contain the COVID-19 pandemic, the study provides evidence for a significant association between school closures and reduced COVID-19 infections. By optimizing the existing incomplete evidence base on the role of school closures in pandemic control, this finding can support involved stakeholders and contribute to strengthening future approaches to pandemic prevention.

Iron Status and Associated Factors among Canadian Women: Results from the Canadian Health Measures Survey.

BACKGROUND: Iron deficiency and overload may negatively impact women's health. There has been limited assessment of iron status and its associated factors among Canadian women. OBJECTIVES: This study investigated associations of various sociodemographic, lifestyle, medication, and dietary factors with body iron stores among pre- and postmenopausal women in Canada. METHODS: Analyses were conducted using cross-sectional, nationally representative survey and biomarker data from women aged 20-79 y (n = 6362) in the Canadian Health Measures Survey (2009-2017). Body iron stores were assessed by measuring serum concentrations of ferritin (SF). Information on potential correlates was collected during an in-home interview. Multivariable linear regression analyses were performed to evaluate associations with SF concentration, and logistic regression was used to estimate associations with iron deficiency (SF <15 µg/L) or elevated iron stores (SF >150 µg/L). RESULTS: Geometric mean SF concentrations were significantly higher in postmenopausal than in premenopausal women (73.2 versus 33.8 µg/L; P < 0.001). The prevalence of iron deficiency among pre- and postmenopausal women was 16.0% and 4.0%, respectively, whereas that of elevated iron stores was 2.7% and 21.0%, respectively. After simultaneous adjustment for multiple factors, including high-sensitivity CRP (inflammation marker), we found that age, East/Southeast Asian (versus White) race/ethnicity, alcohol, and red meat consumption were positively associated with SF concentration among pre- and postmenopausal women. In addition, aspirin use and dairy consumption were inversely associated with SF concentration among postmenopausal women only. Similar patterns were observed for associations with elevated iron stores among postmenopausal women, whereas higher grain consumption was associated with an increased prevalence of iron deficiency among premenopausal women. CONCLUSIONS: Sociodemographic, lifestyle, medication, and dietary factors are correlated with iron status determined by SF concentration among Canadian women. The findings may have implications for intervention strategies aimed at optimizing body iron stores in pre- and postmenopausal women.

Chronic kidney disease of unknown aetiology: A comprehensive review of a global public health problem.

The term chronic kidney disease of unknown aetiology (CKDu) refers to chronic kidney disease (CKD) in the absence of diabetes, long-standing hypertension, glomerulonephritis, obstructive uropathy or other apparent causes. An increasing number of CKDu cases have been reported from Latin America, Sri Lanka, India and others over the last two decades. These regional nephropathies share the following common attributes: (a) they affect low-to-middle income countries with tropical climates, (b) involve predominantly rural agricultural communities, (c) male predilection, (d) absence of significant proteinuria and hypertension, and (e) chronic tubulointerstitial nephritis on kidney biopsy. The current body of literature suggests that CKDu may be caused by heat stress, agrochemicals, contaminated drinking water or heavy metals; however, considerable regional disparities in CKDu research make it difficult to establish a common causal link. In the absence of a definite aetiology, specific preventive and therapeutic interventions are lacking. Improvement of working conditions of farmers and labourers, provision of safe drinking water and changes in agricultural practices are some of the measures that have been implemented; however, there is lack of data to assess their impact on the incidence and progression of CKDu. There is a need for a concerted global effort to address the current knowledge gaps, and to develop effective and sustainable strategies to tackle this devastating disease.

Patient characteristics and testing over COVID-19 waves 1 and 2 from the first German COVID-19 testing unit in Munich, Germany.

BACKGROUND: In Munich, the first German case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected on 27 January 2020 at the Division of Infectious Diseases and Tropical Medicine of the University Hospital LMU Munich (DIDTM), and consecutively the Covid Testing Unit was established. Germany advocated several public health measures to control the outbreak. This study investigates the effects of measures on health service utilization in the public, which in turn can alter case numbers and test positivity rates. METHOD: Our retrospective observational study was conducted to determine the effects of public health measures on the utilization of a testing facility and positivity rates from the first operational COVID-19 testing facility in Munich for waves 1 and 2 over a period of 14 months. This was accomplished by comparing trends in client characteristics including age, gender, symptoms, and socio-demographic aspects over time to non-pharmaceutical measures in Germany. To depict trend changes in testing numbers over time, we developed a negative binomial model with multiple breakpoints. RESULTS: In total 9861 tests were conducted on 6989 clients. The clients were mostly young (median age: 34), female (60.58%), and asymptomatic (67.89%). Among those who tested positive for SARS-CoV-2, 67.72% were symptomatic while the percentage was 29.06% among those who tested negative. There are other risk factors, but a SARS-CoV-2-positive colleague at work is the most prominent factor. Trend changes in the clients' testing numbers could be attributed to the implementation of various public health measures, testing strategies, and attitudes of individuals toward the pandemic. However, test positivity rates did not change substantially during the second wave of the pandemic. CONCLUSION: We could show that implementation or changes in public health measures have a strong effect on the utilization of testing facilities by the general public, which independently of the true epidemiological background situation can result in changing test numbers.

Do blood metals influence lipid profiles? Findings of a cross-sectional population-based survey.

Dyslipidemia, an imbalance of lipids and a major risk factor for cardiovascular disease, has been associated with elevated blood and urine levels of several heavy metals. Using data from a Canadian Health Measures Survey (CHMS), we tested associations between blood levels of cadmium, copper, mercury, lead, manganese, molybdenum, nickel, selenium, and zinc, and the lipids triglycerides (TG), total cholesterol (TC), low density lipoproteins (LDL), high density lipoproteins (HDL) and apolipoproteins A1 (APO A1), and B (APO B). All adjusted associations between single metals and lipids were positive and significant, except for APO A1 and HDL. The joint effect of an interquartile range increase in heavy metals was positively associated with percentage increases of TC, LDL and APO B of 8.82% (95%CI: 7.06, 10.57), 7.01% (95%CI: 2.51, 11.51) and 7.15% (95%CI: 0.51, 13.78), respectively. Future studies are warranted to determine if reducing environmental exposure to heavy metals favorably influences lipid profiles and the risk of cardiovascular disease.

Co-creating public health measures with adolescents in municipalities: municipal actors' views on inhibitors and promoters for adolescent involvement.

AIM: To explore what municipal actors consider as inhibiting and promoting adolescents' involvement in public health measures in municipalities. METHODS: A qualitative study with individual and group interviews was conducted among 15 municipal actors who were central in involving adolescents from five Norwegian municipalities participating in the National Programme for Public Health Work in Municipalities (2017-2027). In addition, participatory observation of project activities was done in two municipalities. A data-driven thematic analysis was applied to analyse data. RESULTS: In the analysis, we developed four themes, including both inhibitors and promoters for adolescent involvement: (a) Timeframe challenges in adolescent involvement; (b) Lack of necessary knowledge and awareness among adolescents; (c) Limited competencies and resources in the project groups; and (d) Facilitators' attitudes on and perceptions of adolescent involvement. CONCLUSIONS: This study reports factors that are important to consider when facilitating involvement processes with young people. Findings suggest that further work should be done to ensure involvement of adolescents in public health measures in municipalities, and actors involving adolescents must be provided with competence and resources to ensure such participation.

Experiences, coping strategies and perspectives of people in Malaysia during the COVID-19 pandemic.

BACKGROUND: A nationwide Movement Control Order (MCO) was enforced in Malaysia on 18 March 2020 in view of the global COVID-19 pandemic. Malaysia implemented various public health measures and later raced against time to administer COVID-19 vaccines when they became available. As a result of various public health measures to curb the spread of the virus, people in Malaysia faced unprecedented circumstances and new challenges. This study addressed the knowledge gap in our understanding the experiences, coping strategies and perspectives of the people in Malaysia about infection countermeasures by investigating their experiences during the COVID-19 pandemic. METHODS: A sequential mixed method approach was used to conduct an online survey and in-depth interviews among residents in Malaysia. A total of 827 respondents participated in the online survey from 1st May to 30th June 2020. Nineteen in-depth interviews were conducted online and by phone with key informants and members of the public, who were selected through maximum variation purposive sampling between 2nd May 2020 to 20th December 2021. The semi-structured interviews employed a phenomenological approach and transcripts were analysed using thematic analysis. The survey data were analysed using descriptive statistics in Stata 15.0. RESULTS: The survey reflected significant economic impacts of the pandemic, the maximum number of days that people could cope during the MCO, and their coping strategies, which generally entailed changes in lifestyle. The internet and social media were vital platforms to mitigate against the impact of public health measures. Thematic analysis of the interview data revealed participant experiences and perceptions of COVID-19 and public health measures in four main themes: (1) work and business; (2) emotional impact (3) coping with change and (4) the COVID-19 vaccine. CONCLUSIONS: This study provides insights into the experiences, coping strategies and perspectives of people in Malaysia living through the first-ever MCO during the COVID-19 pandemic. Such insights into COVID-19-related public health measures are pertinent for successfully planning and implementing future responses to pandemics.

Face masks considerably reduce COVID-19 cases in Germany.

We use the synthetic control method to analyze the effect of face masks on the spread of COVID-19 in Germany. Our identification approach exploits regional variation in the point in time when wearing of face masks became mandatory in public transport and shops. Depending on the region we consider, we find that face masks reduced the number of newly registered severe acute respiratory syndrome coronavirus 2 infections between 15% and 75% over a period of 20 days after their mandatory introduction. Assessing the credibility of the various estimates, we conclude that face masks reduce the daily growth rate of reported infections by around 47%.

Fight Against the Mandatory COVID-19 Immunity Passport on Twitter: Natural Language Processing Study.

BACKGROUND: To contain and curb the spread of COVID-19, the governments of countries around the world have used different strategies (lockdown, mandatory vaccination, immunity passports, voluntary social distancing, etc). OBJECTIVE: This study aims to examine the reactions produced by the public announcement of a binding political decision presented by the president of the French Republic, Emmanuel Macron, on July 12, 2021, which imposed vaccination on caregivers and an immunity passport on all French people to access restaurants, cinemas, bars, and so forth. METHODS: To measure these announcement reactions, 901,908 unique tweets posted on Twitter (Twitter Inc) between July 12 and August 11, 2021, were extracted. A neural network was constructed to examine the arguments of the tweets and to identify the types of arguments used by Twitter users. RESULTS: This study shows that in the debate about mandatory vaccination and immunity passports, mostly "con" arguments (399,803/847,725, 47%; χ26=952.8; P<.001) and "scientific" arguments (317,156/803,583, 39%; χ26=5006.8; P<.001) were used. CONCLUSIONS: This study shows that during July and August 2021, social events permeating the public sphere and discussions about mandatory vaccination and immunity passports collided on Twitter. Moreover, a political decision based on scientific arguments led citizens to challenge it using pseudoscientific arguments contesting the effectiveness of vaccination and the validity of these political decisions.

Influence of affective states on informant impression of neuropsychiatric symptoms in people living with MCI.

Objectives: Alzheimer's disease (AD) and mild cognitive impairment (MCI) are often accompanied by neuropsychiatric symptoms (NPS; e.g. depression/apathy/irritability) causing challenges for people living with dementia/caregivers and predicting worse disease progression. Accurately assessing NPS is critical to research on AD/MCI. However, there are limitations to both self-reports and clinician evaluations; the field often relies on informants to assess NPS. Informants' perception of NPS are influenced by disease and caregiver factors that may lead to biased assessments. We aimed to assess the relationship between participants self-reported affective states (valence/arousal) and informant-reported NPS.Methods: Data from a double-blinded intervention design (primarily testing neurostimulation's effect on NPS) were used to examine the relationship between participant-reported affective states and informant-reported NPS over 1 month. Forty participants (24 females) with MCI and NPS (mean age = 71.7, SD = 7) were enrolled along with informants (primarily spouses/partners) who regularly interact with participants. NPS assessment occurred weekly and at pre- and post-intervention, and participant-reported affective states were assessed at 14 timepoints.Results: Generalized Estimating Equations showed that participant levels of arousal, but not valence, were significantly related to corresponding informant-reported NPS at weekly (arousal: B= -0.59, SE = 0.27, Wald's χ2 = 4.61, p=.032; valence: B = 0.17, SE = 0.19, Wald's χ2 = 0.80, p=.37) and pre-/post- (arousal: B= -4.00, SE = 1.58, Wald's χ2 = 6.42, p=.011; valence: B= -3.34, SE = 1.80, Wald's χ2 = 3.43, p=.06) assessments.Conclusion: The findings indicate that informant-reported NPS may be more strongly influenced by arousal, and informants may be less attuned to valence in people living with MCI.

Health Utilities Index Mark 3 scores for children and youth: Population norms for Canada based on cycles 5 (2016 and 2017) and 6 (2018 and 2019) of the Canadian Health Measures Survey.

Background: Utility scores are an important tool for evaluating health-related quality of life. Utility score norms have been published for Canadian adults, but no nationally representative utility score norms are available for children and youth. Data and methods: Health Utilities Index Mark 3 (HUI3) data from two recent cycles of the Canadian Health Measures Survey (i.e., 2016 and 2017, and 2018 and 2019) were used to provide utility score norms for children aged 6 to 11 years and adolescents aged 12 to 17 years. Children younger than 14 years answered the HUI3 under the supervision of an adult, while older children answered without supervision. Utility scores were reported as a weighted average (95% confidence intervals [CIs]) and median values (interquartile range). Utility scores were stratified by sociodemographic and medical characteristics of the child or adolescent. Regression analyses were used to identify predictors of utility scores. All results were weighted using sampling weights provided by Statistics Canada. Results: Among the 2,297,136 children aged 6 to 11 years and the 2,329,185 adolescents aged 12 to 17 years in the weighted sample, the average utility scores were 0.95 (95% CI: 0.94 to 0.95) and 0.89 (95% CI: 0.87 to 0.90), respectively. Approximately 60% of the children and 34% of the adolescents had a utility score of 1.00. Analyses identified several factors associated with utility scores (e.g., age, chronic condition and income levels), although differences were observed between children and adolescents. Interpretation: This study provides utility score estimates based on a nationally representative sample of Canadian children and youth. Further research examining the determinants of utility scores of children and adolescents is warranted.

On the measurement of healthy lifespan inequality.

BACKGROUND: Current measures to monitor population health include indicators of (i) average length-of-life (life expectancy), (ii) average length-of-life spent in good health (health expectancy), and (iii) variability in length-of-life (lifespan inequality). What is lacking is an indicator measuring the extent to which healthy lifespans are unequally distributed across individuals (the so-called 'healthy lifespan inequality' indicators). METHODS: We combine information on age-specific survival with the prevalence of functional limitation or disability in Spain (2014-2017) by sex and level of education to estimate age-at-disability onset distributions. Age-, sex- and education-specific prevalence rates of adult individuals' daily activities limitations were based on the GALI index derived from Spanish National Health Surveys held in 2014 and 2017. We measured inequality using the Gini index. RESULTS: In contemporary Spain, education differences in health expectancy are substantial and greatly exceed differences in life expectancy. The female advantage in life expectancy disappears when considering health expectancy indicators, both overall and across education groups. The highly educated exhibit lower levels of lifespan inequality, and lifespan inequality is systematically higher among men. Our new healthy lifespan inequality indicators suggest that the variability in the ages at which physical daily activity limitations start are substantially larger than the variability in the ages at which individuals die. Healthy lifespan inequality tends to decrease with increasing educational attainment, both for women and for men. The variability in ages at which physical limitations start is slightly higher for women than for men. CONCLUSIONS: The suggested indicators uncover new layers of health inequality that are not traceable with currently existing approaches. Low-educated individuals tend to not only die earlier and spend a shorter portion of their lives in good health than their highly educated counterparts, but also face greater variation in the eventual time of death and in the age at which they cease enjoying good health-a multiple burden of inequality that should be taken into consideration when evaluating the performance of public health systems and in the elaboration of realistic working-life extension plans and the design of equitable pension reforms.

Trends over two decades in life expectancy with complex health problems among older Swedes: implications for the provision of integrated health care and social care.

BACKGROUND: Due to population aging, it is essential to examine to what extent rises in life expectancy (LE) consist of healthy or unhealthy years. Most health expectancy studies have been based on single health measures and have shown divergent trends. We used a multi-domain indicator, complex health problems (CHP), indicative of the need for integrated medical and social care, to investigate how LE with and without CHP developed in Sweden between 1992 and 2011. We also addressed whether individuals with CHP more commonly lived in the community in 2011 compared to earlier years. METHODS: CHP were defined as having severe problems in at least two of three health domains related to the need for medical and/or social care: symptoms/diseases, cognition/communication, and mobility. The Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), a nationally representative survey of the Swedish population aged ≥ 77 years with waves in 1992, 2002 and 2011 (n≈2000), was used to estimate the prevalence of CHP. Age- and gender-specific death rates were obtained from the Human Mortality Database. The Sullivan method was deployed to calculate the remaining life expectancy with and without CHP. The estimates were decomposed to calculate the contribution of changes from morbidity and mortality to the overall trends in LE without CHP. RESULTS: Between 1992 and 2011, both total LE (+ 1.69 years [95% CI 1.56;1.83] and LE without CHP (+ 0.84 years [-0,87;2.55]) at age 77 increased for men, whereas LE at age 77 increased for women (+ 1.33 [1.21;1.47]) but not LE without CHP (-0.06 years [-1.39;1.26]). When decomposing the trend, we found that the increase in LE with CHP was mainly driven by an increase in the prevalence of CHP. Among individuals with CHP the proportion residing in care homes was lower in 2011 (37%) compared to 2002 (58%) and 1992 (53%). CONCLUSIONS: The findings, that an increasing number of older people are expected to live more years with CHP, and increasingly live in the community, point towards a challenge for individuals and families, as well as for society in financing and organizing coordinated and coherent medical and social services.

Effects of traditional Cantonese opera songs on Cantonese-speaking, community-dwelling older adults' cognitive and psychological function, well-being, and health.

Objectives: Experiencing multi-sensory cognitive stimulation through the enjoyment of Cantonese opera songs, with their lively rhythms, familiar folk tales, meaningful lyrics and pleasant scenarios, has the potential to increase neuroplasticity and prevent cognitive decline.Methods: This prospective pre- and post-test quasi-experimental randomised controlled trial design study aimed to explore the social benefits of older adults' active participation in practising Cantonese opera songs as compared with passive participation (as an audience) and a non-interventional control group on cognitive function psychological function, functional independence, well-being and health.Results: By recruiting a group of older adults who were receiving day activities social service in Hong Kong. Thirty participants were randomly allocated to active participation in Cantonese opera (ACO). They participated in practising Cantonese opera songs. Thirty-four participants were assigned to passive participation in Cantonese opera (PCO). They received passive intervention by listening to and appreciating the opera songs as a social event. Thirty-one participants were used as a control group and received no similar training. (Results) ACO caused a positive change in cognitive function as compared to PCO and to no intervention, which implies that active learning and practise of opera songs benefits global cognitive function. The psychological function of the participants in the PCO group showed an elevated positive affect and a reduced negative affect. A statistically significant difference was noted in the time effect among the physical domains of health status, functional independence and well-being of participants who underwent Cantonese opera intervention.