Incentivizing Healthy Snacks During Out-of-School Time Through Grocery Store Partnerships.

CONTEXT: Volunteer-led out-of-school-time (OST) programs, such as 4-H, scouting, and youth sports, reach a large population of children and are positioned to offer opportunities for healthy eating. However, cost is a barrier to providing healthy snacks such as fruits and vegetables (FVs) during OST. OBJECTIVE: Offering discounts through grocery store partnerships has shown promise in addressing this barrier in structured, staff-led after-school programs. We tested this model in volunteer-led OST programs and evaluated it using mixed methods. DESIGN/SETTING: The Snack It Up (SIU) intervention was designed to promote FV snacks to volunteer-led OST programs through weekly $5 grocery store discounts. Participation was limited to 1 leader per program. PARTICIPANTS: Thirty-five of 36 recruited OST program leaders completed the study; 16 were enrolled in SIU and 19 in a comparison group. MAIN OUTCOME MEASURES: We assessed the following: (1) discount redemption among SIU leaders; (2) snacks served by SIU and comparison group leaders via photographs from 3 to 4 OST program sessions during SIU implementation; and (3) SIU leader perspectives using key informant interviews before and after implementation. RESULTS: SIU leaders saved an average of $48.75 on FV snacks throughout the intervention ($2.90 per week, more than one-fifth of typical self-reported spending on snacks). SIU leaders also served a greater frequency (100% of sessions vs 75%, P < .001) and variety of FVs (an average of 3.5 types per session vs 1.3, P < .001) and fewer salty/sweet snacks (0.0 vs 1.3 types per session, P < .001) than those in the comparison group and expressed positive impressions of SIU. CONCLUSIONS: Partnerships between OST programs and grocery stores are a promising avenue for promoting healthier snacks during OST.

Measuring, valuing and including forgone childhood education and leisure time costs in economic evaluation: Methods, challenges and the way forward.

Economic evaluations carried out to inform the allocation of finite public funds ought to take into account all relevant costs and benefits. When such evaluations adopt a societal perspective, it is important that they include 'time-related' costs arising from productivity and leisure time losses due to receipt of care, ill health or both. For programmes that relate to children, similar costs arise from forgone time, though there is a distinct lack of insights into how such costs should be identified, measured and valued. We set out to explore how forgone time-including absence from formal education and childhood leisure time-can be estimated and incorporated into economic evaluations. To do so, we look at theories and approaches to time valuation proposed in different disciplines and we discuss their suitability for use in health economics research. We find that, while there is a sizeable literature on time valuation methods in education, labour and transportation economics, much of this is not directly applicable to economic evaluation of health care interventions for children. We identify gaps in existing methods and practice, we outline challenges in moving forwards and we provide a list of considerations aiming to assist researchers in deciding whether, and how, to include foregone time-related costs in economic evaluation.

Estimating the cost-effectiveness of salt reformulation and increasing access to leisure centres in England, with PRIMEtime CE model validation using the AdViSHE tool.

BACKGROUND: PRIMEtime CE is a multistate life table model that can directly compare the cost effectiveness of public health interventions affecting diet and physical activity levels, helping to inform decisions about how to spend finite resources. This paper estimates the costs and health outcomes in England of two scenarios: reformulating salt and expanding subsidised access to leisure centres. The results are used to help validate PRIMEtime CE, following the steps outlined in the Assessment of the Validation Status of Health-Economic decision models (AdViSHE) tool. METHODS: The PRIMEtime CE model estimates the difference in quality adjusted life years (QALYs) and difference in NHS and social care costs of modelled interventions compared with doing nothing. The salt reformulation scenario models how salt consumption would change if food producers met the 2017 UK Food Standards Agency salt reformulation targets. The leisure centre scenario models change in physical activity levels if the Birmingham Be Active scheme (where swimming pools and gym access is free to residents during defined periods) was rolled out across England. The AdViSHE tool was developed by health economic modellers and divides model validation into five parts: validation of the conceptual model, input data validation, validation of computerised model, operational validation, and other validation techniques. PRIMEtime CE is discussed in relation to each part. RESULTS: Salt reformulation was dominant compared with doing nothing, and had a 10-year return on investment of £1.44 (£0.50 to £2.94) for every £1 spent. By contrast, over 10 years the Be Active expansion would cost £727,000 (£514,000 to £1,064,000) per QALY. PRIMEtime CE has good face validity of its conceptual model and has robust input data. Cross-validation produces mixed results and shows the impact of model scope, input parameters, and model structure on cost-per-QALY estimates. CONCLUSIONS: This paper illustrates how PRIMEtime CE can be used to compare the cost-effectiveness of two different public health measures affecting diet and physical activity levels. The AdViSHE tool helps to validate PRIMEtime CE, identifies some of the key drivers of model estimates, and highlights the challenges of externally validating public health economic models against independent data.

Does tourism investment improve the energy efficiency in transportation and residential sectors? Evidence from the OECD economies.

This paper investigates the impact of tourism investments on energy efficiency across the transportation and residential sectors of 32 Organization for Economic Co-operation and Development economies. Using annual data from 1995 to 2012, we employ various panel econometric techniques to achieve the study objectives. Given the nature of variables, the paper applies panel autoregressive distributed lag models to estimate the long-run elasticities of energy intensity. The long-run estimates confirm that tourism investments play an essential role in improving energy efficiency across the transportation and residential sectors. Furthermore, the results show that both the foreign direct investment inflows and trade openness also play a considerable role in reducing energy uses across these sectors. Finally, the findings suggest that the tourism investments Granger cause energy efficiency of transportation and residential sectors in the short-run. Given these findings, the paper adds considerable value to the empirical literature and also provides various policy- and practical implications.

Designing drunkenness: How pubs, bars and nightclubs increase alcohol sales.

Using ethnographic data, this paper investigates the techniques used inside pubs, bars and nightclubs to solicit and sustain alcohol consumption among patrons. Focus is on venues with the majority of patrons belonging to the age group of approximately 15-35 years. The paper identifies a number of techniques, both overt and covert, including: alcohol advertising; special offers (e.g. 'Happy Hours' and 'all you can drink' specials); bartenders' use of strategic intimacy, flirtation, and encouragements to buy more; speed drinking devices (e.g. shot glasses, 'beer bongs' and large pitchers); and architectural features that hamper moderate drinking while accelerating the purchase and intake of alcohol. These techniques were used most extensively in low-priced venues with the youngest patrons (e.g. themed chain pubs) and less so in more expensive venues with more adult patrons (e.g. craft beer bars). The paper argues that youth-oriented drinking venues may be conceived as staged atmospheres of consumption where individuals are seduced and compelled into purchasing alcohol. A team of 12 researchers collected the data through interviews and observations in pubs, bars and nightclubs in four cities across Denmark.

Re-evaluating the environmental impacts of tourism: does EKC exist?

The study investigates the long-run impact of tourism development on ecological footprint by employing the time-varying coefficient cointegration approach (TVC), in addition to the conventional cointegration techniques in the case of Azerbaijan for the period of 1996-2014. Based on the TVC estimation results, the coefficient of tourism development, which is the income elasticity of environmental degradation, was found to be time invariant. The paper uses energy consumption, trade, urbanization, and institutional quality indicators as control explanatory variables. The estimation results revealed that trade and energy consumption have statistically significant and positive impact on ecological footprint, while the coefficients of the other explanatory variables were found to be insignificant. Both the conventional estimation methods and the TVC concluded that, for the relationship between ecological footprint and tourism development, the EKC hypothesis is not present in Azerbaijan. Policy implications for the resource-rich economies have been discussed.

Danceterias como espaço de lazer: o cenário legislativo posterior ao desastre na boate Kiss / Dance clubs as leisure space: the legislative scenario after the disaster at Kiss nightclub / Discotecas como espacios de ocio: el escenario legislativo posterior al desastre en la boate Kiss

Este estudo objetiva analisar as ações do poder público para com os estabelecimentos privados de lazer (danceterias) no âmbito da legalidade, posterior ao desastre na Boate KISS. Utilizamos como caminho a Análise Documental, como a Lei Complementar nº 14.376, de 26 de dezembro de 2013, o Inquérito Policial da boate KISS e a mídia impressa Diário de Santa Maria e, a Análise de Conteúdo. Inferimos a mobilização do poder público, posterior ao desastre, na criação de legislações que garantissem a segurança nas danceterias, em especial a Lei Kiss, bem como sua flexibilização, explicitando que o sistema econômico e interesses privados são balizadores da política e das relações entre o público e o privado. O desastre da Boate KISS registra a gravidade de riscos na esfera do lazer e nas tecnologias que incitam desejos, a necessidade de garantia de direitos sociais e de equidade social.

This study aims to analyze the actions of the public power towards private leisure establishments (dance clubs) in the scope of legality, after the disaster at KISS Nightclub. We used as a way the Document Analysis (Complementary Law nº 14.376, of December 26, 2013, the Police Investigation of the KISS Nightclub and the print media Diário de Santa Maria) and the Content Analysis. We inferred the mobilization of the public power, after the disaster, in the creation of legislations that would guarantee safety in the dance clubs, especially the Kiss Law, as well as its flexibility, explaining that the economic system and private interests are benchmarks of politics and of the relations between the public and the private. The KISS Nightclub disaster registers the seriousness of risks in the leisure sphere and in the technologies that incite desires, and the need to guarantee social rights and social equity.

Este estudio objetiva analizar las acciones del poder público hacia establecimientos privados de ocio (discotecas) en el ámbito de la legalidad posterior al desastre en la Boate Kiss. Utilizamos como instrumento el Análisis Documental de la Ley Complementar n.° 14.376, de 26 de diciembre de 2013, la investigación policial de la Boate Kiss, noticias del periódico Diário de Santa Maria, y el análisis de contenido. Inferimos la movilización del poder público, posterior al desastre, en la creación de legislaciones que garanticen la seguridad en discotecas, en especial la Ley Kiss y su flexibilización, evidenciando que el sistema económico e intereses privados son balizadores de la política y de relaciones entre el público y el privado. El desastre de la Boate Kiss registra la gravedad de riesgos en el ámbito del ocio y en las tecnologías que incitan deseos, la necesidad de garantía de derechos sociales y de equidad social.

Socioeconomic inequality in screen time frequency in children and adolescents: the weight disorders survey of the CASPIAN IV study.

BACKGROUND: This study aimed to assess the socioeconomic inequality and determinants of screen time (ST) frequency in Iranian children and adolescents. METHODS: This nationwide study was conducted as part of a national school-based surveillance program among 36,486 students consisting of 50.79% boys and 74.23% urban inhabitants, aged 6-18 years, living in urban and rural areas of 30 provinces of Iran. Socioeconomic inequality in ST, including the time spent for ST, watching TV and leisure-time working with computer, was assessed across quintiles of SES using concentration index (C) and slope index of inequality (SII). RESULTS: Overall, 36,486 students completed the study (response rate 91.25%). Their mean (SD) age was 12.14 (3.36) years. The national estimation of frequency of ST was 31.66% (95% CI 31.16-32.17) with ascending change from 20.80% (95% CI 19.81-21.82) to 36.66% (95% CI 35.47-37.87) from the first to the last quintal of SES. Estimated C value at national level was positive (0.08), which indicate inequality was in favor of low SES groups. Considering the SII values, at national level [- 0.16 (- 0.39, 0.06)], the absolute difference in ST frequency between the bottom and top of the socioeconomic groups had descending trends. In multivariate logistic regression model, family history of obesity, generalized obesity and age were the main significant determinants of prolonged ST, watching TV, and computer working (P < 0.001). CONCLUSIONS: Socioeconomic inequality in ST frequency was in favor of low SES groups. These findings are useful for health policies, better programming and future complementary analyses.

Non-healthcare costs of hepatitis C: a systematic review.

INTRODUCTION: There is an increasing interest in the indirect (or non-healthcare) costs of hepatitis C virus (HCV). Areas covered: Systematic review of original studies on the non-healthcare costs of HCV published in English or Spanish between January 2000 and March 2017. 19 studies addressing non-healthcare cost of HCV were included in the analysis. All studies but one contain treatments with monotherapy or dual therapy prior to the recent introduction of innovative and highly effective direct acting antivirals (DAAs). Five studies estimate the incremental non-healthcare cost of HCV with a control group, which is regarded as high-quality methodology. The incremental annual non-healthcare costs of HCV in untreated patients compared with non-HCV patients are €4,209 in the US, and taking data from 5 European countries costs range from €280 in the UK to €659 in France. Expert commentary: Available studies may be underestimating the true burden of non-healthcare costs for HCV as they are all partial studies, mainly including absenteeism and premature mortality estimates. Moreover, there is a need for studies addressing non-healthcare costs of HCV in settings where new treatments with DAAs have been implemented, as they are probably changing the current and future burden of the disease.

Using local authority entrance charges to tackle inequalities in physical activity? A qualitative study of leisure and public health perspectives.

Background: Reducing or eliminating entrance charges for the public use of leisure facilities is one potential tool that local authorities (LA) have to reduce inequalities in physical activity (PA). Facility charges are likely to be a greater barrier to access for those who have lower incomes. Methods: Semi-structured 1-to-1 and group interviews were conducted with 33 leisure and public health professionals in seven LAs in north-west England. We investigated how approaches to pricing varied in these settings and rationales influencing decision making. Results: Welfare orientated (e.g. affordability) and commercial drivers (e.g. income generation) featured most prominently across areas. Pricing policies placed less direct focus on public health goals, although tackling inactivity was articulated as part of leisure's role more generally. Local targeting of free/concessionary offers was also defined and implemented differently. Decision makers described navigating competing pressures of providing services for the public 'good' yet remaining financially viable. Conclusion: Many LAs are reviewing the extent of subsidy for facilities or are considering whether to invest public health budgets in leisure. The findings offer evidence of how pricing decisions are made and the approaches adopted in practice as well as the conflicting priorities for decision makers within an austerity context.

The economic costs of mental health-related discrimination.

OBJECTIVE: To estimate and compare the economic costs of mental health-related discrimination in the domains of health care, relationships and participation in leisure activities in England between 2011 and 2014. METHOD: A subsample of the Viewpoint survey was interviewed using the Costs of Discrimination Assessment Questionnaire in 2011 and 2014. Information on the impact of discrimination on healthcare use, help seeking from family and friends and participation in leisure activities was recorded. Pattern of contacts, costs and predictor of costs were examined. RESULTS: Our findings showed higher costs of health service use for individuals who reported experiences of discrimination in healthcare settings in 2011 compared with those who did not (mean difference £625, P-value 0.019). Individuals who reported experiences of discrimination in relationships in 2014 had higher healthcare costs than those who did not (mean difference £418, P -value 0.034). There was some evidence of a reduction in overall levels of healthcare use, leisure activities and support from families over time. Discrimination did not significantly affect help seeking from family/friends or leisure activities. CONCLUSION: There is some evidence that discrimination is related to increased healthcare costs. A prospective study is needed to better understand the consequences of these effects.

Barriers to Leisure-Time Physical Activities in Individuals with Spinal Cord Injury.

This study investigated the personal, environmental, and activity barriers to leisure-time physical activities (LTPAs) among individuals with spinal cord injury (SCI). A survey instrument was administered to 85 participants with SCI. Personal barriers to LTPAs included issues involving motivation, pain, scheduling, and financial resources. Environmental barriers marked the issues regarding availability and accessibility to specialized programs, activities, and professional services. Activity barriers included limitations in equipment, training, and personal skills required by the selected activities. Significant negative correlations were found between these barriers and the levels of physical activity and satisfaction with physical activity. While working with clients with SCI, occupational therapists should identify those LTPA barriers and possible solutions in order to establish individualized action plans for enhancing participation in LTPAs.

The Greening Role of Tour Operators.

This paper shows that the tour operators (TOs) can play a coordinating role in the adoption of environmental management upstream the tourism supply chain. This is done using a dynamic model to analyze the environmental management adoption by hotels in a tourism destination induced by a TO. The TO can create incentives to greening hotels' management through the sharing of an environmental price premium. We show that the extent of green management adoption depends on interest rate, the willingness to pay for environmental quality, and hotels' organizational inertia. We also show how the financial yields from green management are shared between TOs and hotels. Finally, we consider a destination manager that subsidizes hotels' green management. If the destination manager does not take the greening role of TOs into account, she could mistake the true trade-off that she faces between the destination's economic and environmental outcomes for the win-win setting that characterizes the general problem.

Barriers associated with frequency of leisure-time physical activity among Brazilian adults of different income strata.

This study aimed to estimate the prevalence of the main perceived barriers to leisure-time physical activity (LTPA) and their associations with the frequency of LTPA in a representative sample of industrial workers from Brazil (n = 47,477), according to their income strata (low income: ≤$US280, middle income: $US281-$US1400, and high income: ≥$US1401). Data were collected between 2006 and 2008 via questionnaires about the main perceived barrier to LTPA and the frequency of LTPA. Multinomial logistic regression was performed to evaluate differences among groups. There was a lower prevalence of regular practice of LTPA in the low- (15.8%) and middle-income strata (18.2%) than among the individuals of the high-income stratum (27.6%). A large proportion of workers who regularly participated in LTPA reported no barriers (low: 43.1%; middle: 46.8%; high: 51.6%). Additional obligations and fatigue were the two most common perceived barriers in all family income strata among participants who engaged in different frequencies of LTPA. The odds for all perceived barriers showed a positive trend related to frequency of LTPA (from regular to no LTPA), with higher values according to income. In summary, the ordering of the main perceived barriers to LTPA differed according to workers' income stratum and frequency of engaging in LTPA.

Should Cost-Effectiveness Analysis Include the Cost of Consumption Activities? AN Empirical Investigation.

There has been a debate on whether cost-effectiveness analysis should consider the cost of consumption and leisure time activities when using the quality-adjusted life year as a measure of health outcome under a societal perspective. The purpose of this study was to investigate whether the effects of ill health on consumptive activities are spontaneously considered in a health state valuation exercise and how much this matters. The survey enrolled patients with inflammatory bowel disease in Germany (n = 104). Patients were randomized to explicit and no explicit instruction for the consideration of consumption and leisure effects in a time trade-off (TTO) exercise. Explicit instruction to consider non-health-related utility in TTO exercises did not influence TTO scores. However, spontaneous consideration of non-health-related utility in patients without explicit instruction (60% of respondents) led to significantly lower TTO scores. Results suggest an inclusion of consumption costs in the numerator of the cost-effectiveness ratio, at least for those respondents who spontaneously consider non-health-related utility from treatment. Results also suggest that exercises eliciting health valuations from the general public may include a description of the impact of disease on consumptive activities.

Exploring the critical quality attributes and models of smart homes.

Research on smart homes has significantly increased in recent years owing to their considerably improved affordability and simplicity. However, the challenge is that people have different needs (or attitudes toward smart homes), and provision should be tailored to individuals. A few studies have classified the functions of smart homes. Therefore, the Kano model is first adopted as a theoretical base to explore whether the functional classifications of smart homes are attractive or necessary, or both. Second, three models and test user attitudes toward three function types of smart homes are proposed. Based on the Kano model, the principal results, namely, two "Attractive Quality" and nine "Indifferent Quality" items, are found. Verification of the hypotheses also indicates that the entertainment, security, and automation functions are significantly correlated with the variables "perceive useful" and "attitude." Cost consideration is negatively correlated with attitudes toward entertainment and automation. Results suggest that smart home providers should survey user needs for their product instead of merely producing smart homes based on the design of the builder or engineer.

The dynamic interaction between combustible renewables and waste consumption and international tourism: the case of Tunisia.

This paper employs the autoregressive distributed lag (ARDL) bounds methodological approach to investigate the relationship between economic growth, combustible renewables and waste consumption, carbon dioxide (CO2) emissions, and international tourism for the case of Tunisia spanning the period 1990-2010. The results from the Fisher statistic of both the Wald test and the Johansen test confirm the presence of a long-run relationship among the variables under investigation. The stability of estimated parameters has been tested, while Granger causality tests recommend a short-run unidirectional causality running from economic growth and combustible renewables and waste consumption to CO2 emissions, a bidirectional causality between economic growth and combustible renewables and waste consumption and unidirectional causality running from economic growth and combustible renewables and waste consumption to international tourism. In the long-run, the error correction terms confirm the presence of bidirectional causality relationships between economic growth, CO2 emissions, combustible renewables and waste consumption, and international tourism. Our long-run estimates show that combustible renewables and waste consumption increases international tourism, and both renewables and waste consumption and international tourism increase CO2 emissions and output. We recommend that (i) Tunisia should use more combustible renewables and waste energy as this eliminates wastes from touristic zones and increases the number of tourist arrivals, leading to economic growth, and (ii) a fraction of this economic growth generated by the increase in combustible renewables and waste consumption should be invested in clean renewable energy production (i.e., solar, wind, geothermal) and energy efficiency projects.