The behavioural costs of overcrowding for gregarious cave-dwelling bats.

Bats are known for their gregarious social behaviour, often congregating in caves and underground habitats, where they play a pivotal role in providing various ecosystem services. Studying bat behaviour remains an underexplored aspect of bat ecology and conservation despite its ecological importance. We explored the costs and impacts of overcrowding on bat social behaviour. This study examined variations in bat behavioural patterns between two distinct groups, aggregated and non-aggregated male Rousettus amplexicaudatus, within the Monfort Bat Cave Sanctuary on Mindanao Island, Philippines. We found significant variations in the incident frequencies of various bat behavioural activities, particularly aggression and movement, between these two groups. The increase in aggregation was closely related to negative social behaviour among bats. In contrast, sexual behaviour was significantly related to the positive behaviour of individual bats and was headed in less crowded areas. The disparities in bat behaviour with an apparent decline in bat social behaviour because of overcrowding, with more aggressive behaviours emerging, align with the 'behavioural sink' hypothesis. Our study underscores the importance of considering habitat quality and resource availability in the management and conservation of bat colonies, as these factors can reduce the occurrence of aggressive and negative social behaviours in colonies with high population density by providing alternative habitats.

Using Andersen's behavioural model to examine individual and contextual factors associated with dental service utilization in Brazil.

OBJECTIVES: The study aimed to examine individual and contextual factors associated with the frequency of dental service utilization among adolescents, adults and older adults Brazilians. METHODS: This cross-sectional study used secondary data from the Brazilian 2019 National Health Survey (94 114 individuals). The outcome 'when was your last dental appointment?' was categorized into three groups: up to 1 year, more than 1 year and never had a dental appointment. Andersen's behavioural model was used to select contextual and individual variables. Multinomial logistic regression analysis was performed to calculate the odds ratio (OR) and 95% confidence intervals (95% CI). RESULTS: The following variables showed increased probability to the outcome had the last dental appointment more than 1 year ago: older adult, illiterate or incomplete primary school, and without private dental insurance. The outcome never had a dental appointment was significantly associated with illiterate (OR 26.65; 95% CI 17.63-40.29), male (OR 2.38; 95% CI 2.17-2.61), without private dental insurance (OR 5.20; 95% CI 3.48-7.76), self-rated oral health as bad or very bad (OR 2.67; 95% CI 2.31-3.09), household not enrolled in primary care teams (OR 1.29; 95% CI 1.11-1.49), household in a rural area (OR 1.86; 95% CI 1.69-2.05), high household crowding (OR 1.08; 95% CI 1.04-1.14) and low household income per capita (OR 0.99; 95% CI 0.99-0.99). CONCLUSIONS: This study showed that contextual and individual factors induce inequity in dental appointments. Moreover, Andersen's behavioural model demonstrated inequitable access for dental services in Brazil, in which social structure and enabling characteristics, rather than the need for the service, determine who receives health care. Living in a household enrolled in primary care teams favoured regular dental appointments. Thus, these findings may help policymakers improve health access by expanding coverage of dental services in primary health care.

Childhood socio-economic circumstances and dementia: prospective register-based cohort study of adulthood socio-economic and cardiovascular health mediators.

BACKGROUND: This study analysed the association between childhood socio-economic circumstances and the risk of dementia, and investigated the mediating role of potentially modifiable risk factors including adulthood socio-economic position and cardiovascular health. METHODS: We used a 10% sample of the 1950 Finnish population census linked with subsequent population and health registers (n = 95 381). Information of socio-economic characteristics, family structure and housing conditions at the age of 0-15 years was obtained from the 1950 census. We identified cohort members who developed dementia in 2000-2018 using national hospital, medication and death registers. Discrete time survival analysis using logistic regression and mediation analysis applying the Karlson-Holm-Breen (KHB) method were employed. RESULTS: An excess risk of dementia was observed for household crowding [odds ratio (OR) = 1.10; 95% CI 1.02-1.18 for 3 to <4 persons per heated room; OR = 1.19; 95% CI 1.11-1.27 for ≥4 persons], single-father family (OR = 1.27; 95% CI 1.07-1.51) and eastern and northern region of residence (OR = 1.19; 95% CI 1.10-1.28). The effects of single-father family and region of residence were mostly direct with adulthood characteristics mediating 14% and 29% of the total effect, respectively. The largest indirect effect was observed for household crowding mediated through adulthood socio-economic position (47-65%). CONCLUSIONS: The study shows that childhood socio-economic circumstances are associated with dementia, and that the underlying mechanisms only partly relate to adulthood socio-economic position and cardiovascular health. Socio-economic and health interventions targeted at families with children may carry long-term benefits by contributing to a lower dementia risk in later life.

Housing Insecurity, Housing Conditions, and Breastfeeding Behaviors for Medicaid-Eligible Families in Urban Settings.

BACKGROUND: Research exploring associations between exposure to social determinants of health and breastfeeding is needed to identify breastfeeding barriers. Housing insecurity and household conditions (chaos and crowding) may affect breastfeeding by increasing maternal stress and discomfort and decreasing time available to breastfeed. RESEARCH AIM: We aimed to examine the relationships between housing insecurity, breastfeeding exclusivity intention during the early postnatal period, and breastfeeding exclusivity at 6 months postpartum among a sample "at risk" for suboptimal breastfeeding rates. METHODS: This study is a secondary data analysis of a longitudinal study at two time periods. Data were collected from English- and Spanish-speaking, Medicaid-eligible mother-infant dyads (N = 361) at near-birth and child aged 6 months, in New York City and Pittsburgh. Structural equation modeling was used to examine direct and indirect effects of housing insecurity on breastfeeding exclusivity at child aged 6 months. RESULTS: The path model showed that experiencing more markers of housing insecurity (i.e., foreclosure/eviction threat, history of homelessness, late rent) was predictive of significantly lower breastfeeding exclusivity at 6 months. This was partially mediated through less exclusive breastfeeding intention during the early postnatal period. Greater household crowding was associated with 6-month breastfeeding exclusivity when mediated by intention. Household crowding had differential effects by study site and participant race/ethnicity. CONCLUSION: Refinement of housing insecurity as a multi-dimensional construct can lead to the development of standardized data collection instruments, inform future methodological decisions in research addressing social determinants of health, and can inform the development of responsive individual- and structural-level interventions.The data used in this study were collected as part of the SMART Beginnings Randomized Controlled Trial (NCT02459327 registered at ClinicalTrials.gov).

Development of a multidimensional housing and environmental quality index (HEQI): application to the American Housing Survey.

BACKGROUND: Substandard housing conditions and hazardous indoor environmental exposures contribute to significant morbidity and mortality worldwide. Housing indices that capture the multiple dimensions of healthy housing are important for tracking conditions and identifying vulnerable households. However, most indices focus on physical deficiencies and repair costs and omit indoor environmental exposures, as few national data sources routinely collect this information. METHODS: We developed a multidimensional Housing and Environmental Quality Index (HEQI) based on the World Health Organization's Housing and Health Guidelines and applied it to the 2019 American Housing Survey (AHS). The HEQI consisted of ten domains associated with poor health: household fuel combustion, dampness and mold, pests and allergens, lead paint risk, high indoor temperatures, low indoor temperatures, household crowding, injury hazards, inadequate water and sanitation, and ventilation. We evaluated the validity and performance of the HEQI against three housing characteristics (i.e., year built, monthly rent costs, unit satisfaction rating) and two established indices (i.e., Adequacy Index, Poor Quality Index). RESULTS: Approximately 79% (92 million) of U.S. households reported at least one HEQI domain associated with poor health (mean per household: 1.3; range: 0,8). Prevalent domains included household fuel combustion (61.4%), dampness and mold (15.9%), inadequate water and sanitation (14.3%), and injury hazards (11.9%). Pests and allergens, low indoor temperatures, and injury hazards were consistently associated with older homes, lower rent costs, and lower unit satisfaction. Compared to established housing indices, the HEQI captured four new environmental domains which enabled the identification of 57.7 million (63%) more households with environmental risk factors like mold, cockroaches, crowding, household fuel combustion, and higher building leakage. CONCLUSIONS: Indoor environmental exposures are prevalent in U.S. households and not well-captured by existing housing indices. The HEQI is a multidimensional tool that can be used to monitor indoor environmental exposures and housing quality trends in the U.S. Some domains, including radon, pesticides, asbestos, noise, and housing accessibility could not be assessed due to the lack of available data in the AHS. The mounting evidence linking residential environmental exposures with adverse health outcomes underscore the need for this data in the AHS and other national surveys.

Impact of COVID-19 shocks, precarity and mediating resources on the mental health of residents of share housing in Victoria, Australia: an analysis of data from a two-wave survey.

OBJECTIVES: COVID-19 lockdown measures have challenged people's mental health, especially among economically vulnerable households. The objective of this study was to investigate the impact of exposure to COVID-19 shocks (defined as job loss, living cost pressures and changing housing conditions throughout the lockdown period) and double precarity (defined as precarity in housing and employment) on mental health outcomes for members of share households as well as the mediating effects of a range of resources. DESIGN: We conducted a two-wave survey of occupants of share housing in June and October 2020 during a prolonged period of population lockdown. Research design involved fixed effects ordered logit regression models to assess the mental health consequences of baseline precarity and COVID-related shocks. SETTING: Victoria, Australia. PARTICIPANTS: We surveyed 293 occupants of share houses (mean age 34 SD 11.5, 56% female). Members of share houses (where individuals are unrelated adults and not in a romantic relationship) are more likely to be young, casually employed, visa-holders and low-income. OUTCOME MEASURES: We measured household composition, housing and employment precarity, access to government support, household crowding, social networks and COVID-19 shocks. We used a self-reported measure of mental health. RESULTS: Those exposed to COVID-19 shocks reported a 2.7 times higher odds of mental health deterioration (OR 2.7, 95% CI 1.53 to 4.85). People exposed to double precarity (precarity in both housing and employment) reported 2.4 times higher odds of mental health deterioration (OR 2.4, 95% CI 0.99 to 5.69). Housing inadequacy and lack of access to sufficient government payments explained 14.7% and 7% of the total effect of double precarity on mental health, respectively. CONCLUSIONS: Results indicate that residents of group households characterised by pre-existing precarity were vulnerable to negative mental health effects during lockdown. Access to sufficient government payments and adequate housing buffered this negative effect.

Socioeconomic disparities and household crowding in association with the fecal microbiome of school-age children.

The development of the gut microbiome occurs mainly during the first years of life; however, little is known on the role of environmental and socioeconomic exposures, particularly within the household, in shaping the microbial ecology through childhood. We characterized differences in the gut microbiome of school-age healthy children, in association with socioeconomic disparities and household crowding. Stool samples were analyzed from 176 Israeli Arab children aged six to nine years from three villages of different socioeconomic status (SES). Sociodemographic data were collected through interviews with the mothers. We used 16 S rRNA gene sequencing to characterize the gut microbiome, including an inferred analysis of metabolic pathways. Differential analysis was performed using the analysis of the composition of microbiomes (ANCOM), with adjustment for covariates. An analysis of inferred metagenome functions was performed implementing PICRUSt2. Gut microbiome composition differed across the villages, with the largest difference attributed to socioeconomic disparities, with household crowding index being a significant explanatory variable. Living in a low SES village and high household crowding were associated with increased bacterial richness and compositional differences, including an over-representation of Prevotella copri and depleted Bifidobacterium. Secondary bile acid synthesis, d-glutamine and d-glutamate metabolism and Biotin metabolism were decreased in the lower SES village. In summary, residential SES is a strong determinant of the gut microbiome in healthy school-age children, mediated by household crowding and characterized by increased bacterial richness and substantial taxonomic and metabolic differences. Further research is necessary to explore possible implications of SES-related microbiome differences on children's health and development.

Analysis of an Alternative Model of Definitive Care For Low-Acuity Emergency Calls: A Natural Experiment.

BACKGROUND: Emergency medical services (EMS) diversion strategies attempt to limit the impact of low-acuity care on emergency department (ED) crowding, but evidence supporting these strategies is scarce. OBJECTIVE: This study aims to measure the effect of a treat-in-place and alternative destination program on ED transports and EMS utilization. METHODS: We used a natural experiment study design to measure effects of a pilot prehospital diversion program on ED transport, number of EMS vehicles dispatched, and EMS time on task for low-acuity emergency calls in a midsized urban setting characterized by a high prevalence of health disparities, concentrated poverty, and limited access to primary care between October 2018 and January 2020. We also used direct variable cost to estimate the return on investment attributable to avoided ED visits. RESULTS: Of 3725 calls that met eligibility criteria, the program responded to 1084 (29.1%), with 56.7% of those resulting in an ED visit, compared with 64.6% of the 492 control calls that were eligible but were dispatched when program services were unavailable. Of 1084 calls receiving response, 213 (19.6%) were enrolled in the program, and 8.5% of those were transported by EMS to the ED. Adjusted results show EMS time on task was 23.4 min less for enrolled calls vs. controls. The program can achieve a positive return on investment by enrolling 2.9 patients/day. CONCLUSIONS: A prehospital diversion program reduced ED visits and EMS transport times. Improved targeting of patients for enrollment would further increase the intervention's efficacy and cost savings.

Likely behaviours of people under emergency circumstances in hospitals: A cross-sectional study.

Hospitals, which play an important role in reducing injuries and casualties, must be prepared for a crowd of people in emergencies. The present study aimed to survey and collect data on the likely behaviours of people under emergency circumstances in hospitals in order to improve emergency response plans in these places. The target population was all individuals present in three hospitals from Tabriz (including patients, companions and treatment staff), and the sample size was 1145. A questionnaire was administered to this population in order to collect the data. The comparison of different groups was performed based on participants' gender and their role. Results showed that, in general, everyone in the surveyed hospitals is more likely to choose a reactive strategy rather than a preventive strategy as well as a cooperative strategy rather than a competitive strategy, and less willing to use lifts during emergencies. Comparing different strategies utilized by different people resulting from ordered logit models revealed that there are significant differences in evacuation strategies between men and women as well as between treatment staff and all respondents. Men were more likely to select a proactive strategy rather than a reactive strategy compared to women. Also, the treatment staff group were more likely to employ a cooperative strategy and less likely to use a competitive strategy compared to other people. In view of the role of hospitals, the results of this study can play a major role in policy-making to predict the behaviour of different individuals in healthcare settings and perform needs assessment to consider the necessary facilities or raining required for different people in various countries.

Inequalities in overcrowding [February 2022]: environmental health inequalities: fact sheet series

This fact sheet series documents the magnitude of environmental health inequalities within countries in the WHO European Region. Environmental health inequalities relate to socioeconomic, sociodemographic or spatial differences in exposure to environmental health risk factors and to differences in health status caused by environmental conditions. The overcrowding fact sheet provides available data on the unequal distribution of living space within countries in the Region, updating earlier assessments.

Why Does Influenza Hit the Poor More Than the Rich? A 1931 Social Epidemiology Article That Broke New Ground in the History of Confounding, Mediation, and Interaction.

In 1931, Edgar Sydenstricker, the former statistician of the US Public Health Service, challenged the common belief that the 1918 influenza outbreak had affected "the rich and the poor alike." Using data from 112,317 participants in a 1918 US national survey, he observed that, on the contrary, both morbidity and mortality from the flu had been higher among the poor than among the rich. To explain these differences, Sydenstricker stratified the analyses by 2 measures of affluence collected in the survey: "economic status" (from "very poor" to "well-to-do") and household crowding (i.e., number of people per household room). Economic status was associated with influenza attack rates within categories of crowding, but not the opposite, suggesting that characteristics of poverty other than "household congestion" were the culprit of the poor's higher influenza burden. Attack rate ratios for influenza in infants and older adults were greater for the poor or very poor. Sydenstricker reanalyzed an already 12-year-old data set in the context of the Great Depression to build the evidence base relating poverty to ill health. For this purpose he used a stratification approach to assess confounding, mediation, and interaction before the concepts were formally named.

Assessment of energy vulnerability in urban crowded space of Indian Himalaya.

Energy poverty poses a serious threat to the urban population residing in Himalayan towns. The present study aims to assess energy vulnerability in the urban settlement of Indian Himalayan Region (IHR). The study addresses energy access and affordability; its requirement, practices, and efficiency, considering the quality of electricity, dwelling type, transport facilities, energy expenditure, household chores (cooking, heating, cooling, lighting, etc.), awareness, and social interactions. The study uses an energy vulnerability framework based on IPCC indices to investigate the status of energy vulnerability in the urban space of Dehradun, the Indian Himalayan Region. The primary data was collected from two circular regions of the city, an area close to the central place and an area outlying from the central place, respectively. The energy vulnerability index was 0.31 and 0.34 with varying degrees of exposure, sensitivity, and adaptive capacity. The findings reveal that energy vulnerability could jeopardize the well-being of the society and could be mitigated through appropriate policy measures, intensive support to sensitive societies, and a developmental approach focusing on sustainable energy. The study provides a theoretical base to conduct extensive research addressing a similar issue in other Himalayan towns.

Association of Socioeconomic Characteristics With Disparities in COVID-19 Outcomes in Japan.

IMPORTANCE: Socioeconomic factors in the disparities in COVID-19 outcomes have been reported in studies from the US and other Western countries. However, no studies have documented national- or subnational-level outcome disparities in Asian countries. OBJECTIVE: To assess the association between regional COVID-19 outcome disparities and socioeconomic characteristics in Japan. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study collected and analyzed confirmed COVID-19 cases and deaths (through February 13, 2021) as well as population and socioeconomic data in all 47 prefectures in Japan. The data sources were government surveys for which prefecture-level data were available. EXPOSURES: Prefectural socioeconomic characteristics included mean annual household income, Gini coefficient, proportion of the population receiving public assistance, educational attainment, unemployment rate, employment in industries with frequent close contacts with the public, household crowding, smoking rate, and obesity rate. MAIN OUTCOMES AND MEASURES: Rate ratios (RRs) of COVID-19 incidence and mortality by prefecture-level socioeconomic characteristics. RESULTS: All 47 prefectures in Japan (with a total population of 126.2 million) were included in this analysis. A total of 412 126 confirmed COVID-19 cases (326.7 per 100 000 people) and 6910 deaths (5.5 per 100 000 people) were reported as of February 13, 2021. Elevated adjusted incidence and mortality RRs of COVID-19 were observed in prefectures with the lowest household income (incidence RR: 1.45 [95% CI, 1.43-1.48] and mortality RR: 1.81 [95% CI, 1.59-2.07]); highest proportion of the population receiving public assistance (1.55 [95% CI, 1.52-1.58] and 1.51 [95% CI, 1.35-1.69]); highest unemployment rate (1.56 [95% CI, 1.53-1.59] and 1.85 [95% CI, 1.65-2.09]); highest percentage of workers in retail industry (1.36 [95% CI, 1.34-1.38] and 1.45 [95% CI, 1.31-1.61]), transportation and postal industries (1.61 [95% CI, 1.57-1.64] and 2.55 [95% CI, 2.21-2.94]), and restaurant industry (2.61 [95% CI, 2.54-2.68] and 4.17 [95% CI, 3.48-5.03]); most household crowding (1.35 [95% CI, 1.31-1.38] and 1.04 [95% CI, 0.87-1.24]); highest smoking rate (1.63 [95% CI, 1.60-1.66] and 1.54 [95% CI, 1.33-1.78]); and highest obesity rate (0.93 [95% CI, 0.91-0.95] and 1.17 [95% CI, 1.01-1.34]) compared with prefectures with the most social advantages. Among potential mediating variables, higher smoking rate (RR, 1.54; 95% CI, 1.33-1.78) and obesity rate (RR, 1.17; 95% CI, 1.01-1.34) were associated with higher mortality RRs, even after adjusting for prefecture-level covariates and other socioeconomic variables. CONCLUSIONS AND RELEVANCE: This cross-sectional study found a pattern of socioeconomic disparities in COVID-19 outcomes in Japan that was similar to that observed in the US and Europe. National policy in Japan could consider prioritizing populations in socially disadvantaged regions in the COVID-19 response, such as vaccination planning, to address this pattern.

Preventive behaviours and family inequalities during the COVID-19 pandemic: a cross-sectional study in China.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is an international public health threat, and people's participation in disease-related preventive behaviours is the key to controlling infectious diseases. This study aimed to assess the differences in adopting preventive behaviours among populations to explore potential individual and household factors and inequalities within families. METHODS: This online survey was conducted in April 2020. The directional stratified convenient sampling method was used to select 4704 participants from eight provinces in eastern, central, and western China. The questionnaire included demographic information, household variables, and five target prevention behaviours. The chi-squared test, binary multilevel model, and Mantel-Haenszel hierarchical analysis were used for data analysis in the study. RESULTS: Approximately 71.2% of the participants had appropriate outdoor prevention, and 32.9% of the participants had indoor protection in place. Sharing behaviours (P < 0.001) and education level (P < 0.001) were positively associated with adopting preventive measures. The inhibiting effect of household crowding and stimulating effect of high household income on preventive behaviours were determined in this study. Household size was negatively associated with living area (ß = -0.057, P < 0.05) and living style (ß = -0.077, P < 0.05). Household income was positively associated with age (ß = 0.023, P < 0.05), and relationship with friends (ß = 0.053, P < 0.05). Vulnerable groups, such as older adults or women, are more likely to have inadequate preventive behaviours. Older adults (OR = 1.53, 95% CI 1.09-2.15), women (OR = 1.37, 95% CI 1.15-1.64), and those with more than 2 suspected symptoms (OR = 1.85, 95% CI 1.07-3.19) were more likely to be affected by the inhibiting effect of household crowding, while the stimulating effect of high household income was limited in these groups. CONCLUSIONS: Inequalities in COVID-19 prevention behaviours exist between families and inadequate adoption of prevention by vulnerable groups are noteworthy. This study expands the research perspective by emphasizing the role of household factors in preventive behaviours and by focusing on family inequalities. The government should use traditional media as a platform to enhance residents' public health knowledge. Targeted additional wage subsidies, investments in affordable housing, financial support for multigenerational households, and temporary relocation policies may deserve more attention. Communities could play a critical role in COVID-19 prevention.

Overcoming COVID-19 vaccination resistance when alternative policies affect the dynamics of conformism, social norms, and crowding out.

What is an effective vaccination policy to end the COVID-19 pandemic? We address this question in a model of the dynamics of policy effectiveness drawing upon the results of a large panel survey implemented in Germany during the first and second waves of the pandemic. We observe increased opposition to vaccinations were they to be legally required. In contrast, for voluntary vaccinations, there was higher and undiminished support. We find that public distrust undermines vaccine acceptance, and is associated with a belief that the vaccine is ineffective and, if enforced, compromises individual freedom. We model how the willingness to be vaccinated may vary over time in response to the fraction of the population already vaccinated and whether vaccination has occurred voluntarily or not. A negative effect of enforcement on vaccine acceptance (of the magnitude observed in our panel or even considerably smaller) could result in a large increase in the numbers that would have to be vaccinated unwillingly in order to reach a herd-immunity target. Costly errors may be avoided if policy makers understand that citizens' preferences are not fixed but will be affected both by the crowding-out effect of enforcement and by conformism. Our findings have broad policy applicability beyond COVID-19 to cases in which voluntary citizen compliance is essential because state capacities are limited and because effectiveness may depend on the ways that the policies themselves alter citizens' beliefs and preferences.

Crowding-Out or Crowding-In: Government Health Investment and Household Consumption.

This paper explores the relationship of government health investment and household consumption by applying a panel fixed effects model and Sobel-Goodman mediation tests to inland Chinese provinces. The empirical results highlight that government health investment has a crowding-in effect and can thus promote household consumption. Furthermore, the promotion effect on non-medical health consumption is greater than that on medical health consumption. The promotion effect of government health investment on rural household consumption is higher than that on urban household consumption, and the promotion effect on household consumption for northern provinces is higher than that in southern provinces. This heterogeneous effect is closely related to the difference between urban and rural development; and the economic levels of the northern and South regions. The mediation tests found that government health investment mainly promotes regional economic growth, and then increases household consumption. In the economic and social development process, the government should implement more effective medical and health care measures to increase social medical and health investment to improve the consumption level of households.