Investigating the relationship between health and gender equality: What role do maternal, reproductive, and sexual health services play?

Examining the causal nexus between health services and gender equality is of paramount significance in policy formulation and academic inquiry. This paper concentrates on maternal, sexual, and reproductive health, offering a critical narrative review of empirical research exploring the causal relationship between enhanced women's health, stemming from either overall healthcare amelioration or specific interventions, and broader gender equality objectives. A conceptual framework is devised to elucidate the causal pathways between health and gender equality across various dimensions. The final review encompasses 30 empirical papers, revealing both direct and indirect effects of improved maternal, reproductive, and sexual health outcomes on labour participation and educational investment, with fertility decisions and autonomy serving as primary intermediary factors. Evidence predominantly indicates that interventions like contraception, family planning, and abortion policies yield enduring effects beyond health, influencing reproductive choices. Specific medical procedures, such as caesarean deliveries and sterilization, also impact fertility and labour market outcomes. Furthermore, public healthcare infrastructure contributes to combating gender-based violence by facilitating incident reporting and access to protection. Recognizing, documenting, and monitoring these co-benefits arising from improved women's health are pivotal for delineating future health sector priorities and advancing the global gender equality and sustainable development agenda.

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics.

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Health-related quality of life and healthcare costs of symptoms and cardiovascular disease events in patients with atrial fibrillation: a longitudinal analysis of 27 countries from the EURObservational Research Programme on Atrial Fibrillation general long-term registry.

AIMS: We examine the effects of symptoms and cardiovascular disease (CVD) events on health-related quality of life (HRQOL) and healthcare costs in a European population with atrial fibrillation (AF). METHODS AND RESULTS: In the EURObservational Research Programme on AF long-term general registry, AF patients from 250 centres in 27 European countries were enrolled and followed for 2 years. We used fixed effects models to estimate the association of symptoms and CVD events on HRQOL and annual healthcare costs. We found significant decrements in HRQOL in AF patients in whom ST-segment elevation myocardial infarction (STEMI) [-0.075 (95% confidence interval -0.144, -0.006)], angina or non-ST-elevation myocardial infarction (NSTEMI) [-0.037 (-0.071, -0.003)], new-onset/worsening heart failure [-0.064 (-0.088, -0.039)], bleeding events [-0.031 (-0.059, -0.003)], thromboembolic events [-0.071 (-0.115, -0.027)], mild symptoms [0.037 (-0.048, -0.026)], or severe/disabling symptoms [-0.090 (-0.108, -0.072)] occurred during the follow-up. During follow-up, annual healthcare costs were associated with an increase of €11 718 (€8497, €14 939) in patients with STEMI, €5823 (€4757, €6889) in patients with angina/NSTEMI, €3689 (€3219, €4158) in patients with new-onset or worsening heart failure, €3792 (€3315, €4270) in patients with bleeding events, and €3182 (€2483, €3881) in patients with thromboembolic events, compared with AF patients without these events. Healthcare costs were primarily driven by inpatient costs. There were no significant differences in HRQOL or healthcare resource use between EU regions or by sex. CONCLUSION: Symptoms and CVD events are associated with a high burden on AF patients and healthcare systems throughout Europe.

Production, modification and degradation of fructans and fructooligosacharides by enzymes originated from plants.

Non-starch polysaccharides exhibit numerous beneficial health effects but compounds belonging to FODMAP (Fermentable Oligo- Di- and Monosaccharides and Polyols) has been recently connected to several gastrointestinal disorders. This review presents integrated literature data on the occurrence and types of fructans and fructooligosaccharids (classified as FODMAPs) as well as their degrading enzymes present in plants. Plants from the family Asteraceae and many monocotyledones, including families Poaceae and Liliaceae, are the most abundant sources of both fructans and fructan-degrading enzymes. So far, vast majority of publications concerning the application of these specific plants in production of bakery products is related to increase of dietary fibre content in these products. However, there is limited research on their effect on FODMAP content and fibre balance. The authors emphasize the possibility of application of enzyme rich plant extract in food production casting light on the new scientific approach to fibre modification.

Technological properties, shelf life and consumers' acceptance of high-fibre cookies prepared with juice processing by-products.

High dietary fibre cookies were manufactured from non-wheat (triticale, spelt and rye) flours with apple, beetroot and pumpkin pomace powders added as natural colourants. Cookies were characterized by nutritional composition, colour, texture and sensory profile and subjected to a 2-month shelf-life study. Additionally, an acceptability study was done to determine consumers' acceptance of cookies. Cookies prepared from rye flour and pumpkin pomace, as well as cookies prepared from spelt flour and beetroot pomace, can be labelled as 'high fibre' (dietary fibre content of 8.90% and 7.09%, respectively), while cookies prepared from triticale flour and apple pomace can be labelled as a 'source of fibre' (dietary fibre content of 4.50%). No obvious trend in the colour of cookies was observed after storage at room temperature and 40 °C, indicating the stability of natural colourants. Hardness decrease was observed in all samples after storage; however, the acceptability study showed that consumers prefer softer cookies. Sensory analysis showed that there were no signs of rancidity in samples after storage. Although triticale flour and apple pomace sample received the highest liking scores for appearance, odour and taste, all samples had liking ratings higher than 4 (indifferent) and can be further modified to satisfy consumers' demands.

Cardiovascular disease burden due to productivity losses in European Society of Cardiology countries.

OBJECTIVE: Cardiovascular disease (CVD) is the leading cause of death across Europe. We estimated lost earnings (productivity losses) associated with premature mortality due to CVD, and separately for its main sub-categories of coronary heart disease and cerebrovascular disease, across 54 country members of the European Society of Cardiology (ESC). METHODS AND RESULTS: We used a standardized approach to estimate working years and earnings lost due to premature death resulting from CVD across the 54 ESC member countries in 2018. Our population-based approach was based on national data on the number of deaths, employment rates, and earnings by age group and sex. We discounted future working years and earnings lost to present values using a 3.5% annual rate. In 2018, there were 4.4 million deaths due to CVD across the 54 countries, with 7.1 million working years lost. This represented productivity losses due to premature death of €62 billion in 2018. Deaths due to coronary heart disease accounted for 47% (€29 billion) of all CVD costs, and cerebrovascular disease accounted for 18% (€11 billion). Approximately 60% (€37 billion) of all productivity losses occurred in the 28 European Union member states, despite accounting for only 42% (1.8 million) of deaths and 21% (1.5 million) of working years lost across the 54 countries. CONCLUSION: Our study provides a snapshot of the economic consequences posed by premature mortality due to CVD across 54 countries in 2018. The considerable variation across countries highlights the potential gains from policies targeting prevention and care of cardiovascular diseases.

Cardiovascular disease care and outcomes in West and South European countries.

Variations in cardiovascular disease (CVD) burden between West and South European countries are rarely reported. To address this knowledge gap, The Lancet Regional Health-Europe convened experts from a broad range of countries to assess the current state of knowledge of cardiovascular disease inequalities across Europe. This Review is specifically focused on West and South European countries. Mortality, risk factor and economic data for nine West European and six South European countries were sourced from the World Health Organisation, the Global Burden of Disease study and the World Bank. Healthcare data were collected by survey of participating countries. A key finding was of declines in age-standardised mortality rates (ASMRs) across all countries since 1990. In 2019 rates per 100,000 were lower in West European countries in males (279.7 (264.1-335.9) vs 337.2 (323.7-367.2)) and females (196.2 (183.3-228.8) vs 247.3 (232.2-268.3)). Differences in risk factor exposures were small, with the exception of physical activity and dietary factors, but across all countries the prevalence of obesity has increased, affecting >20% of adults in 2019. Healthcare delivery in 2019 showed inequalities with cardiovascular procedure rates lower in South compared with West European countries. Further declines in ASMRs in West and South European countries will require population strategies to reduce obesity and address inequalities in physical activity and dietary factors. Reducing the gap in procedure rates is unlikely to match the beneficial effects of population strategies for reducing CVD burden in South European countries.

FODMAPs-Unknowns for Consumers: First Survey in Serbia.

According to unofficial data, every fifth person in Serbia suffers from some form of irritable bowel syndrome (IBS). Compounds classified as FODMAPs (Fermentable Oligo-, Di-, and Monosaccharides and Polyols) are newly found potential triggers of IBS and a number of associated gastrointestinal disorders. Cereals, predominantly in their wholegrain form, represent the key contributors to the high contents of FODMAPs in wholegrain (high-fiber) bakery products. The current work was structured in a way to systematically evaluate the consumer's knowledge and preferences toward wholegrain and low-FODMAP bakery products. The questionnaire was filled out by 725 respondents, aged from 18 to 86 years. They were informed about the aim of the research and management of anonymous data. The present study is the first detailed survey in this region of Europe, aiming to improve the familiarity with and attitude toward FODMAPs and a low-FODMAP diet by analyzing the different dietary habits regarding wholegrain-cereal-based products among consumers of various ages, genders, places of residence, and education. The results suggest that the respondents are, to some degree, aware of the health benefits of consuming foods with high fiber content while indicating a low level of knowledge about FODMAP compounds and connected topics. Education about contemporary scientific findings and the potentially harmful effects of consuming FODMAP compounds for a population with gastrointestinal disorders and diseases will be imperative in the future.

Collecting Physicians' Preferences on Medical Devices: Are We Doing It Right? Evidence from Italian Orthopedists Using 2 Different Stated Preference Methods.

OBJECTIVES: Physician preference items (PPIs) are high-cost medical devices for which clinicians express firm preferences with respect to a particular manufacturer or product. This study aims to identify the most important factors in the choice of new PPIs (hip or knee prosthesis) and infer about the existence of possible response biases in using 2 alternative stated preference techniques. METHODS: Six key attributes with 3 levels each were identified based on a literature review and clinical experts' opinions. An online survey was administered to Italian hospital orthopedists using type 1 best-worst scaling (BWS) and binary discrete choice experiment (DCE). BWS data were analyzed through descriptive statistics and conditional logit model. A mixed logit regression model was applied to DCE data, and willingness-to-pay (WTP) was estimated. All analyses were conducted using Stata 16. RESULTS: A sample of 108 orthopedists were enrolled. In BWS, the most important attribute was "clinical evidence," followed by "quality of products," while the least relevant items were "relationship with the sales representative" and "cost." DCE results suggested instead that orthopedists prefer high-quality products with robust clinical evidence, positive health technology assessment recommendation and affordable cost, and for which they have a consolidated experience of use and a good relationship with the sales representative. CONCLUSIONS: The elicitation of preferences for PPIs using alternative methods can lead to different results. The BWS of type 1, which is similar to a ranking exercise, seems to be more affected by acquiescent responding and social desirability than the DCE, which introduces tradeoffs in the choice task and is likely to reveal more about true preferences. HIGHLIGHTS: Physician preference items (PPIs) are medical devices particularly exposed to physicians' choice with regard to type of product and supplier.Some established techniques of collecting preferences can be affected by response biases such as acquiescent responding and social desirability.Discrete choice experiments, introducing more complex tradeoffs in the choice task, are likely to mitigate such biases and reveal true physicians' preferences for PPIs.

Asparaginase Treatment of Sea Buckthorn Berries as an Effective Tool for Acrylamide Reduction in Nutritionally Enriched Wholegrain Wheat, Rye and Triticale Biscuits.

Sea buckthorn pomace is a by-product of juice production, which is still rich in bioactive compounds. After drying, the pomace can be effectively used as a valuable addition to bakery products supporting their nutritional value. However, due to the high content of the amino acid asparagine in sea buckthorn, this promising material contributes to the undesirable formation of acrylamide. To reduce the risk from this potentially carcinogenic compound, enzymatic treatment of sea buckthorn with asparaginase was applied, which resulted in a substantial reduction of asparagine content from 1834 mg/kg in untreated dried sea buckthorn pomace to 89 mg/kg in enzymatically treated dried sea buckthorn pomace. 10% substitution of wholegrain cereal flour with enzymatically treated sea buckthorn pomace powder in rye and triticale biscuits resulted in a 35% reduction in acrylamide content, in the case of wholegrain wheat biscuits up to a 64% reduction, compared to biscuits with untreated sea buckthorn pomace powder. This study confirmed that treating fruit with asparaginase is an effective way to reduce health risk caused by acrylamide in biscuits enriched with nutritionally valuable fruit pomace.

Economic burden of cardiovascular diseases in the European Union: a population-based cost study.

BACKGROUND AND AIMS: Cardiovascular disease (CVD) impacts significantly health and social care systems as well as society through premature mortality and disability, with patients requiring care from relatives. Previous pan-European estimates of the economic burden of CVD are now outdated. This study aims to provide novel, up-to-date evidence on the economic burden across the 27 European Union (EU) countries in 2021. METHODS: Aggregate country-specific resource use data on morbidity, mortality, and health, social and informal care were obtained from international sources, such as the Statistical Office of the European Communities, enhanced by data from the European Society of Cardiology Atlas programme and patient-level data from the Survey of Health, Ageing and Retirement in Europe. Country-specific unit costs were used, with cost estimates reported on a per capita basis, after adjustment for price differentials. RESULTS: CVD is estimated to cost the EU €282 billion annually, with health and long-term care accounting for €155 billion (55%), equalling 11% of EU-health expenditure. Productivity losses accounted for 17% (€48 billion), whereas informal care costs were €79 billion (28%). CVD represented a cost of €630 per person, ranging from €381 in Cyprus to €903 in Germany. Coronary heart disease accounted for 27% (€77 billion) and cerebrovascular diseases for 27% (€76 billion) of CVD costs. CONCLUSIONS: This study provides contemporary estimates of the wide-ranging impact of CVD on all aspects of the economy. The data help inform evidence-based policies to reduce the impact of CVD, promoting care access and better health outcomes and economic sustainability.

Prioritizing COVID-19 vaccine allocation in resource poor settings: Towards an Artificial Intelligence-enabled and Geospatial-assisted decision support framework.

OBJECTIVES: To propose a novel framework for COVID-19 vaccine allocation based on three components of Vulnerability, Vaccination, and Values (3Vs). METHODS: A combination of geospatial data analysis and artificial intelligence methods for evaluating vulnerability factors at the local level and allocate vaccines according to a dynamic mechanism for updating vulnerability and vaccine uptake. RESULTS: A novel approach is introduced including (I) Vulnerability data collection (including country-specific data on demographic, socioeconomic, epidemiological, healthcare, and environmental factors), (II) Vaccination prioritization through estimation of a unique Vulnerability Index composed of a range of factors selected and weighed through an Artificial Intelligence (AI-enabled) expert elicitation survey and scientific literature screening, and (III) Values consideration by identification of the most effective GIS-assisted allocation of vaccines at the local level, considering context-specific constraints and objectives. CONCLUSIONS: We showcase the performance of the 3Vs strategy by comparing it to the actual vaccination rollout in Kenya. We show that under the current strategy, socially vulnerable individuals comprise only 45% of all vaccinated people in Kenya while if the 3Vs strategy was implemented, this group would be the first to receive vaccines.

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management.

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Vaccine hesitancy comes in waves: Longitudinal evidence on willingness to vaccinate against COVID-19 from seven European countries.

AIM: This paper investigates the prevalence and determinants of three main states of people's willingness to be vaccinated (WTBV) against COVID-19 - willing, unwilling and hesitant - and the occurrence and predictors of shifts between these states over time. Understanding the dynamics of vaccine intentions is crucial for developing targeted campaigns to increase uptake and emergency response preparedness. STUDY DESIGN: A panel survey consisting of 9 quarterly waves of data collected between April 2020 and January 2022. Baseline data included 24 952 adults from Germany, UK, Denmark, the Netherlands, France, Portugal, and Italy recruited from online panels to construct census-matched nationally representative samples. METHODS AND MEASURES: Self-reported COVID-19 vaccine intention was the main outcome. Multinomial logit random effects models were used to analyze the relationships of interest. All results reported as relative risk ratios (RRR). RESULTS: Hesitancy to get vaccinated was the most unstable vaccine intention, with on average 42% of ever hesitant respondents remaining in this state through future waves, followed by the 'unwilling' (53%) and 'willing (82%). Following COVID-19 news, trust in information from the government, GPs and the WHO, risk preferences, risk perceptions, and confidence in vaccines (or lack thereof) predicted vaccination intention reversals. Risk preferences acted both as an impediment and as a facilitator for the vaccine uptake depending on the initial vaccine intention. CONCLUSIONS AND RELEVANCE: This study revealed the dynamic nature of COVID-19 vaccine intentions and its predictors in 7 European countries. The findings provide insights to policymakers for designing more effective communication strategies, particularly targeted at hesitant and unwilling to vaccinate population groups, to increase vaccine uptake for future public health emergencies.

A repeated cross-sectional analysis on the economic impact of SARS-CoV-2 pandemic at the hospital level in Italy.

Italy was the first country in Europe to be hit by the Severe Acute Respiratory Syndrome Coronavirus 2. Little research has been conducted to understand the economic impact of providing care for SARS-CoV-2 patients during the pandemic. Our study aims to quantify the incremental healthcare costs for hospitalizations associated to being discharged before or after the first SARS-CoV-2 case was notified in Italy, and to a positive or negative SARS-CoV-2 notified infection. We used data on hospitalizations for 9 different diagnosis related groups at a large Italian Research Hospital with discharge date between 1st January, 2018 and 31st December 2021. The median overall costs for a hospitalization increased from 2410EUR (IQR: 1588-3828) before the start of the pandemic, to 2645EUR (IQR: 1885-4028) and 3834EUR (IQR: 2463-6413) during the pandemic, respectively for patients SARS-CoV-2 negative and positive patients. Interestingly, according to results of a generalized linear model, the highest increases in the average costs sustained for SARS-CoV-2 positive patients with respect to patients discharged before the pandemic was found among those with diagnoses unrelated to COVID-19, i.e. kidney and urinary tract infections with CC (59.71%), intracranial hemorrhage or cerebral infarction (53.33), and pulmonary edema and respiratory failure (47.47%). Our study highlights the economic burden during the COVID-19 pandemic on the hospital system in Italy based on individual patient data. These results contribute to the to the debate around the efficiency of the healthcare services provision during a pandemic.

Braving the waves: exploring capability well-being patterns in seven European countries during the COVID-19 pandemic.

The COVID-19 pandemic considerably impacted the lives of European citizens. This study aims to provide a nuanced picture of well-being patterns during the pandemic across Europe with a special focus on relevant socio-economic sub-groups. This observational study uses data from a repeated, cross-sectional, representative population survey with nine waves of data from seven European countries from April 2020 to January 2022. The analysis sample contains a total of 25,062 individuals providing 64,303 observations. Well-being is measured using the ICECAP-A, a multi-dimensional instrument for approximating capability well-being. Average levels of ICECAP-A index values and sub-dimension scores were calculated across waves, countries, and relevant sub-groups. In a fixed effects regression framework, associations of capability well-being with COVID-19 incidence, mortality, and the stringency of the imposed lockdown measures were estimated. Denmark, the Netherlands, and France experienced a U-shaped pattern in well-being (lowest point in winter 2020/21), while well-being in the UK, Germany, Portugal, and Italy followed an M-shape, with increases after April 2020, a drop in winter 2020, a recovery in the summer of 2021, and a decline in winter 2021. However, observed average well-being reductions were generally small. The largest declines were found in the well-being dimensions attachment and enjoyment and among individuals with a younger age, a financially unstable situation, and lower health. COVID-19 mortality was consistently negatively associated with capability well-being and its sub-dimensions, while stringency and incidence rate were generally not significantly associated with well-being. Further investigation is needed to understand underlying mechanisms of presented patterns.

Influence of Ultrasonic and Chemical Pretreatments on Quality Attributes of Dried Pepper (Capsicum annuum).

This study investigates the effects of ultrasound, in combination with chemical pretreatments, on the quality attributes (total phenolic and carotenoid content, antioxidant activity (2,2-Diphenyl-1-picrylhydrazyl assay (DPPH)), ferric-reducing ability (FRAP), CIE L* a* b* color, non-enzymatic browning, rehydration ratio, textural and morphological properties) of red pepper subjected to drying (hot air drying or freeze drying). The fractional factorial design was used to assess the impact of factors. The global Derringer desirability function was used to determine the optimal conditions for the best quality attributes of dried pepper. The drying method influenced total phenolic content, a* (redness), and initial rehydration ratio; pretreatment time significantly affected FRAP antiradical activity, a*, chroma and non-browning index, while pH-value had a significant effect on the texture of dried pepper. Non-enzymatic browning was reduced to 72.6%, while the DPPH antioxidant capacity of freeze-dried peppers was enhanced from 4.2% to 71.9%. Ultrasonic pretreatment led to changes in the pepper morphology, while potassium metabisulfite (KMS) was a more effective additive than citric acid.