Children's Health in London and Luton (CHILL) cohort: a 12-month natural experimental study of the effects of the Ultra Low Emission Zone on children's travel to school.

BACKGROUND: The Ultra-Low Emission Zone (ULEZ), introduced in Central London in April 2019, aims to enhance air quality and improve public health. The Children's Health in London and Luton (CHILL) study evaluates the impact of the ULEZ on children's health. This analysis focuses on the one-year impacts on the shift towards active travel to school. METHODS: CHILL is a prospective parallel cohort study of ethnically diverse children, aged 6-9 years attending 84 primary schools within or with catchment areas encompassing London's ULEZ (intervention) and Luton (non-intervention area). Baseline (2018/19) and one-year follow-up (2019/20) data were collected at school visits from 1992 (58%) children who reported their mode of travel to school 'today' (day of assessment). Multilevel logistic regressions were performed to analyse associations between the introduction of the ULEZ and the likelihood of switching from inactive to active travel modes, and vice-versa. Interactions between intervention group status and pre-specified effect modifiers were also explored. RESULTS: Among children who took inactive modes at baseline, 42% of children in London and 20% of children in Luton switched to active modes. For children taking active modes at baseline, 5% of children in London and 21% of children in Luton switched to inactive modes. Relative to the children in Luton, children in London were more likely to have switched from inactive to active modes (OR 3.64, 95% CI 1.21-10.92). Children in the intervention group were also less likely to switch from active to inactive modes (OR 0.11, 0.05-0.24). Moderator analyses showed that children living further from school were more likely to switch from inactive to active modes (OR 6.06,1.87-19.68) compared to those living closer (OR 1.43, 0.27-7.54). CONCLUSIONS: Implementation of clean air zones can increase uptake of active travel to school and was particularly associated with more sustainable and active travel in children living further from school.

Correction: Does bribery increase maternal mortality? Evidence from 135 Sub-Saharan African regions.

[This corrects the article DOI: 10.1371/journal.pgph.0000847.].

Does bribery increase maternal mortality? Evidence from 135 Sub-Saharan African regions.

About 295,000 women died globally during and following pregnancy and childbirth in 2017. Two-thirds of these deaths occurred in Sub-Saharan Africa. By linking individual and regional data from 135 regions in 17 Sub-Saharan African countries over the period 2002-2018 this study explores how bribery affects maternal mortality in Sub-Saharan Africa. Our results show that the percentage of people who had first-hand experience in bribery is significantly and positively associated with pregnancy related deaths. We find that a 10 p.p. increase in the prevalence of bribery is associated with up to 41 [95% CI: 10-73] additional deaths for every 1,000 pregnancy-related deaths. However, the healthcare system quality appears to be an important moderator. To reduce maternal mortality, policy makers should not only increase investments in healthcare, they need also to implement measures to combat corruption.

Non-randomised feasibility study testing a primary care intervention to promote engagement in an online health community for adults with troublesome asthma: protocol.

INTRODUCTION: In the UK, approximately 4.3 million adults have asthma, with one-third experiencing poor asthma control, affecting their quality of life, and increasing their healthcare use. Interventions promoting emotional/behavioural self-management can improve asthma control and reduce comorbidities and mortality. Integration of online peer support into primary care services to foster self-management is a novel strategy. We aim to co-design and evaluate an intervention for primary care clinicians to promote engagement with an asthma online health community (OHC). Our protocol describes a 'survey leading to a trial' design as part of a mixed-methods, non-randomised feasibility study to test the feasibility and acceptability of the intervention. METHODS AND ANALYSIS: Adults on the asthma registers of six London general practices (~3000 patients) will be invited to an online survey, via text messages. The survey will collect data on attitudes towards seeking online peer support, asthma control, anxiety, depression, quality of life, information on the network of people providing support with asthma and demographics. Regression analyses of the survey data will identify correlates/predictors of attitudes/receptiveness towards online peer support. Patients with troublesome asthma, who (in the survey) expressed interest in online peer support, will be invited to receive the intervention, aiming to reach a recruitment target of 50 patients. Intervention will involve a one-off, face-to-face consultation with a practice clinician to introduce online peer support, sign patients up to an established asthma OHC, and encourage OHC engagement. Outcome measures will be collected at baseline and 3 months post intervention and analysed with primary care and OHC engagement data. Recruitment, intervention uptake, retention, collection of outcomes, and OHC engagement will be assessed. Interviews with clinicians and patients will explore experiences of the intervention. ETHICS AND DISSEMINATION: Ethical approval was obtained from a National Health Service Research Ethics Committee (reference: 22/NE/0182). Written consent will be obtained before intervention receipt and interview participation. Findings will be shared via dissemination to general practices, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05829265.

Freedom of Choice to Vaccinate and COVID-19 Vaccine Hesitancy in Italy.

Despite the availability of effective vaccines that lower mortality and morbidity associated with COVID-19, many countries including Italy have adopted strict vaccination policies and mandates to increase the uptake of the COVID-19 vaccine. Such mandates have sparked debates on the freedom to choose whether or not to get vaccinated. In this study, we examined the people's belief in vaccine choice as a predictor of willingness to get vaccinated among a sample of unvaccinated individuals in Italy. An online cross-sectional survey was conducted in Italy in May 2021. The survey collected data on respondents' demographics and region of residence, socioeconomic factors, belief in the freedom to choose to be vaccinated or not, risk perception of contracting and transmitting the disease, previous vaccine refusal, opinion on adequacy of government measures to address the pandemic, experience in requesting and being denied government aid during the pandemic, and intent to accept COVID-19 vaccination. The analysis employed binary logistic regression models using a hierarchical model building approach to assess the association between intent to accept vaccination and belief in the freedom to choose to vaccinate, while adjusting for other variables of interest. 984 unvaccinated individuals were included in the study. Respondents who agreed that people should be free to decide whether or not to vaccinate with no restrictions on their personal life had 85% lower odds of vaccine acceptance (OR = 0.15; 95% CI, 0.09,0.23) after adjusting for demographic and socioeconomic factors and their risk perception of contracting and transmitting COVID-19. Belief in the freedom to choose whether or not to accept vaccinations was a major predictor of COVID-19 vaccine acceptance among a sample of unvaccinated individuals in Italy in May 2021. This understanding of how individuals prioritize personal freedoms and the perceived benefits and risks of vaccines, when making health care decisions can inform the development of public health outreach, educational programs, and messaging.

Cross-National Vaccine Concerns and Predictors of Vaccine Hesitancy in Not-Fully Vaccinated Individuals: Findings from USA, Canada, Sweden, and Italy.

Vaccine hesitancy is a key contributor to reduced COVID-19 vaccine uptake and remains a threat to COVID-19 mitigation strategies as many countries are rolling out the campaign for booster shots. The goal of our study is to identify and compare the top vaccine concerns in four countries: Canada, Italy, Sweden, and the USA and how these concerns relate to vaccine hesitancy. While most individuals in these countries are now vaccinated, we expect our results to be helpful in guiding vaccination efforts for additional doses, and more in general for other vaccines in the future. We sought to empirically test whether vaccine related concerns followed similar thematic issues in the four countries included in this study, and then to see how these themes related to vaccine hesitancy using data from a cross-sectional survey conducted in May 2021. We applied CFA and created vaccine concern scales for analysis. We then utilized these results in regression-based modeling to determine how concerns related to vaccine hesitancy and whether there were similar or different concerns by country. The results quantitatively highlight that the same vaccine related concerns permeated multiple countries at the same point in time. This implies that COVID-19 vaccination communications could benefit from global collaboration.

Information and vaccine hesitancy: Evidence from the early stage of the vaccine roll-out in 28 European countries.

The success of mass vaccination programs against SARS-CoV-2 hinges on the public's acceptance of the vaccines. During a vaccine roll-out, individuals have limited information about the potential side-effects and benefits. Given the public health concern of the COVID pandemic, providing appropriate information fast matters for the success of the campaign. In this paper, time-trends in vaccine hesitancy were examined using a sample of 35,390 respondents from the Eurofound's Living, Working and COVID-19 (LWC) data collected between 12 February and 28 March 2021 across 28 European countries. The data cover the initial stage of the vaccine roll-out. We exploit the fact that during this period, news about rare cases of blood clots with low blood platelets were potentially linked to the Oxford/AstraZeneca vaccine (or Vaxzeveria). Multivariate regression models were used to analyze i) vaccine hesitancy trends, and whether any trend-change was associated with the link between the AstraZeneca vaccine ii) and blood clots (AstraZeneca controversy), and iii) the suspension among several European countries. Our estimates show that vaccine hesitancy increased over the early stage of the vaccine roll-out (0·002, 95% CI: [0·002 to 0·003]), a positive shift took place in the likelihood of hesitancy following the controversy (0·230, 95% CI: [0·157 to 0·302]), with the trend subsequently turning negative (-0·007, 95% CI: [-0·010 to -0·005]). Countries deciding to suspend the AstraZeneca vaccine experienced an increase in vaccine hesitancy after the suspensions (0·068, 95% CI: [0·04 to 0·095]). Trust in institutions is negatively associated with vaccine hesitancy. The results suggest that SARS-CoV-2 vaccine hesitancy increased steadily since the beginning of the vaccine roll-out and the AstraZeneca controversy and its suspension, made modest (though significant) contributions to increased hesitancy.

Exploring the Association between Misinformation Endorsement, Opinions on the Government Response, Risk Perception, and COVID-19 Vaccine Hesitancy in the US, Canada, and Italy.

The COVID-19 pandemic has highlighted the adverse consequences created by an infodemic, specifically bringing attention to compliance with public health guidance and vaccine uptake. COVID-19 vaccine hesitancy is a complex construct that is related to health beliefs, misinformation exposure, and perceptions of governmental institutions. This study draws on theoretical models and current data on the COVID-19 infodemic to explore the association between the perceived risk of COVID-19, level of misinformation endorsement, and opinions about the government response on vaccine uptake. We surveyed a sample of 2697 respondents from the US, Canada, and Italy using a mobile platform between 21-28 May 2021. Using multivariate regression, we found that country of residence, risk perception of contracting and spreading COVID-19, perception of government response and transparency, and misinformation endorsement were associated with the odds of vaccine hesitancy. Higher perceived risk was associated with lower odds of hesitancy, while lower perceptions of government response and higher misinformation endorsement were associated with higher hesitancy.

The association between COVID-19 policy responses and mental well-being: Evidence from 28 European countries.

This study assesses how the implementation and lifting of non-pharmaceutical policy interventions (NPIs), deployed by most governments, to curb the COVID-19 pandemic, were associated with individuals' mental well-being (MWB) across 28 European countries. This is done both for the general population and across key-groups. We analyze longitudinal data for 15,147 respondents from three waves of the Eurofound-"Living, Working and COVID-19" survey, covering the period April 2020-March 2021. MWB is measured by the WHO-5 index. Our evidence suggests that restriction on international travel, private gatherings, and contact tracing (workplace closures) were negatively (positively) associated with MWB by about, respectively, -0.63 [95% CI: -0.79 to -0.47], -0.24 [95% CI: -0.38 to -0.10], and -0.22 [95% CI: -0.36 to -0.08] (0.29 [95% CI: 0.11 to 0.48]) points. These results correspond to -3.9%, -1.5%, and -1.4% (+1.8%) changes compared to pre-pandemic levels. However, these findings mask important group-differences. Women compared to men fared worse under stay-at-home requirements, internal movement restrictions, private gatherings restrictions, public events cancellation, school closures, and workplace closures. Those residing with children below 12, compared to those who do not, fared worse under public events cancellation, school closures and workplace closures. Conversely, those living with children 12-17, compared to those who do not, fared better under internal movement restrictions and public events cancelling. Western-Europeans vis-à-vis Eastern-Europeans fared better under NPIs limiting their mobility and easing their debts, whereas they fared worse under health-related NPIs. This study provides timely evidence of the rise in inequalities during the COVID-19 pandemic and offers strategies for mitigating them.

COVID-19 Vaccine Concerns about Safety, Effectiveness, and Policies in the United States, Canada, Sweden, and Italy among Unvaccinated Individuals.

Despite the effectiveness of the COVID-19 vaccine, global vaccination distribution efforts have thus far had varying levels of success. Vaccine hesitancy remains a threat to vaccine uptake. This study has four objectives: (1) describe and compare vaccine hesitancy proportions by country; (2) categorize vaccine-related concerns; (3) rank vaccine-related concerns; and (4) compare vaccine-related concerns by country and hesitancy status in four countries-the United States, Canada, Sweden, and Italy. Using the Pollfish survey platform, we sampled 1000 respondents in Canada, Sweden, and Italy and 750 respondents in the United States between 21-28 May 2021. Results showed vaccine-related concerns varied across three topical areas-vaccine safety and government control, vaccine effectiveness and population control, and freedom. For each thematic area, the top concern was statistically significantly different in each country and among the hesitant and non-hesitant subsamples within each county. Concerns related to freedom were the most universal. Understanding the specific concerns among individuals when it comes to the COVID-19 vaccine can help to inform public communications and identify which, if any, salient narratives are global.

Prevalence and changes in food-related hardships by socioeconomic and demographic groups during the COVID-19 pandemic in the UK: A longitudinal panel study.

BACKGROUND: Food insecurity concerns have featured prominently in the UK response to the COVID-19 pandemic. We assess changes in the prevalence of food-related hardships in the UK population from April to July 2020. METHOD: We analysed longitudinal data on food-related hardships for 11,104 respondents from the April-July 2020 waves of the Understanding Society COVID-19 web survey with linked data from the 2017-9 wave of the annual Understanding Society survey. Outcome variables were reports of being hungry but not eating and of being unable to eat healthy and nutritious food in the last week, which were adapted from the Food Insecurity Experience Scale. We used unadjusted estimates to examine changes in population prevalence and logistic regression to assess the association between employment transitions and both outcomes at the individual level. FINDINGS: The prevalence of reporting an inability to eat healthy or nutritious food rose from 3•2% in April to 16•3% in July 2020. The largest increases in being unable to eat healthy or nutritious food were among Asian respondents, the self-employed, and 35-44-year-olds. The prevalence of being hungry but not eating rose from 3•3% in April to 5•1% in July, with the largest increases observed among unemployed individuals below age 65. Those moving from employment to unemployment had higher odds of being hungry but not eating in the last week relative to furloughed individuals (OR = 2•2; p < 0•05; 95% CI: 1•1 to 4•2) and to the persistently employed (OR = 3•5; p < 0•001; 95% CI: 1•8 to 6•9), adjusting for age, highest qualification in 2017-19, net household income in 2017-19 (equivalized), gender, race/ethnicity, number children at home (aged 0-4, 5-15, and 16-18), cohabitation status, and government office region. Respondents moving from employment to unemployment also had higher odds of reporting an inability to eat healthy and nutritious food relative to furloughed individuals (OR = 1•9; p < 0•05; 95% CI: 1•4 to 3•2) and to the persistently employed (OR = 2•0; p < 0•01; 95% CI: 1•2 to 3•4). No statistically significant differences were found between furloughed individuals and the persistently employed in their probability of reporting either outcome. INTERPRETATION: Food-related hardships increased substantially in the UK between April and July 2020, largely driven by reports of an inability to eat healthy and nutritious food. The Coronavirus Job Retention Scheme and Self-Employment Income Support Scheme appeared to have conferred some protection, but more could have been done to mitigate the problems we describe in obtaining affordable food. FUNDING: DS is funded by the Wellcome Trust investigator award. JK and DS are funded by the European Research Council n. 313590 - HRES. VT is funded by the European Research Council n. 694145- IFAMID.

Health care system efficiency and life expectancy: A 140-country study.

Despite the evidence of links between health expenditure and health care efficiency, it is still unclear why countries with similar levels of health expenditures experience different outputs in terms of life expectancy at birth. Health care system efficiency might shed some light on the question. Using output-oriented data envelopment analysis, we compared the health systems of 140 countries in terms of attained life expectancy. Efficiency is determined by the distance from the closest country on the best practice frontier, which identifies the highest attainable life expectancy observed for any given level of health care spending. By using national data form the Human Development Data, we built the efficiency frontier and computed the potential life expectancy increase for each country. The potential improvement was, on average, 5.47 years [95%CI: 4.71-6.27 years]. The least efficient countries (10th percentile of the efficiency score) could improve by 11.78 years, while the most efficient countries (90th percentile of the efficiency score) could only improve by 0.83 years. We then analyzed, with regression analysis stratified by average education level, and by the role of health-related variables in differentiating efficient and inefficient countries from each other. The results suggest that, among countries with lower levels of education, decreasing unemployment and income inequality increases average life expectancy, without increasing health expenditure levels.

The employment and mental health impact of integrated Improving Access to Psychological Therapies: Evidence on secondary health care utilization from a pragmatic trial in three English counties.

OBJECTIVE: Patients with a combination of long-term physical health problems can face barriers in obtaining appropriate treatment for co-existing mental health problems. This paper evaluates the impact of integrating the improving access to psychological therapies services (IAPT) model with services addressing physical health problems. We ask whether such services can reduce secondary health care utilization costs and improve the employment prospects of those so affected. METHODS: We used a stepped-wedge design of two cohorts of a total of 1,096 patients with depression and/or anxiety and comorbid long-term physical health conditions from three counties within the Thames Valley from March to August 2017. Panels were balanced. Difference-in-difference models were employed in an intention-to-treat analysis. RESULTS: The new Integrated-IAPT was associated with a decrease of 6.15 (95% CI: -6.84 to -5.45) [4.83 (95% CI: -5.47 to -4.19]) points in the Patient Health Questionnaire-9 [generalized anxiety disorder-7] and £360 (95% CI: -£559 to -£162) in terms of secondary health care utilization costs per person in the first three months of treatment. The Integrated-IAPT was also associated with an 8.44% (95% CI: 1.93% to 14.9%) increased probability that those who were unemployed transitioned to employment. CONCLUSIONS: Mental health treatment in care model with Integrated-IAPT seems to have significantly reduced secondary health care utilization costs among persons with long-term physical health conditions and increased their probability of employment.

How the internet increases modern contraception uptake: evidence from eight sub-Saharan African countries.

BACKGROUND: Sub-Saharan African (SSA) countries have the highest worldwide levels of unmet need for modern contraception. This has led to persistently high fertility rates in the region, rates which have had major adverse repercussions on the development potential there. Family planning programmes play a key role in improving the uptake of modern contraception, both by fostering women's health and by lowering their fertility. Increasing awareness of contraception benefits is a major component of such programmes. Here, we ask whether internet access can bridge the gap between women's need for modern contraception and women's uptake of the same. METHODS: We use a compendium of data for 125 242 women, aged 15-49, from the Demographic Health Survey, Akamai and International Communication Union data, covering eight SSA countries, for the period 2014-2019. We apply a Two-Stage Least Square model, using as instruments for individual internet exposure the distance to the main server in the country and whether the backbone network in the country has been connected to at least one submarine cable. RESULTS: Internet exposure, measured as women access the internet at least monthly (almost daily), is associated with a positive, 11.4% (95% CI 10.6% to 12.2%) (53.8% (95% CI 13.4% to 94.1%)), increase in modern contraception uptake. Education is an important moderator. Poorly educated women benefit the most from internet exposure. DISCUSSION: Internet exposure appears to have significantly increased the uptake of modern contraception among sub-Saharan women. The poorly educated appear particularly to benefit. There are two mechanisms at play: the internet increases women's knowledge of contraception; and, in parallel, fosters their empowerment.

Trends in the use of mind-altering drugs among European adolescents during the Great Recession.

Despite the growing evidence of health-responses to macroeconomic fluctuations, little research has been carried out on the economic reflexes of licit and illicit drug-consumption, especially among teenagers. This paper uses data on adolescents between 15 and 17 years old from 25 European countries to test, if and how, the substance-use pattern has changed during the Great Recession. The data come from two cross-sectional waves (2007 and 2011) of the European School Survey Project on Alcohol and Other Drugs (ESPAD) (n = 137,989 individuals). One percentage point increase in the unemployment rate is associated with an increase [decrease] in the probability of having tried inhalants and cocaine [ecstasy] at least once, by about 0.005 (95 % CI: 0.004, 0.006) and 0.001 (95 % CI: 0.0001, 0.001) [-0.001 (95 % CI: -0.001, -0.001)] respectively. Social protection expenditure reduces the use of inhalants, whereas ecstasy consumption rises. The pattern for cocaine is unclear.

The quantification of the psychiatric revolution: a quasi-natural experiment of the suicide impact of the Basaglia Law.

BACKGROUND: The Italian 180/1978 reform abolishing asylums is one of the most contested mental health programs ever implemented. It aimed to shift care of mental illness into the community improving outcomes and reducing expenditure. It was a model for successive deinstitutionalization initiatives across Europe and North America. However, there were longstanding concerns that, without expansion of community care, it may have deprived patients with mental illness access to support, placing them at increased risk of suicide. METHODS: Regression discontinuity models were used to quantify the association between the number of suicides and the introduction of the Basaglia Law, disaggregated by age-group and gender, covering 20 Italian regions during the period 1975-84. Models were adjusted for potential socio-demographic confounding factors, region-specific fixed effects and pre-existing time-trends. RESULTS: Italian regions implemented the Basaglia Law to varying degrees over time. We observed that, after adjusting for pre-existing time trends, the implementation was associated with a consistent increase in the number of suicides for all the age-groups [incidence rate ratio, age 15-44: 1.29, 95% confidence interval (CI) 1.18-1.41; age 45-74: 1.45, 95% CI 1.37-1.54] and for both genders (males: 1.47, 95% CI 1.41-1.53; females: 1.36, 95% CI 1.25-1.47). Hospital closure appeared to be an important mediating mechanism. CONCLUSIONS: The Basaglia Law was associated with a significant increase in the number of suicides, with evidence of an association with closures of facilities, leaving those with mental illness with nowhere to go, as the envisioned community care structures failed to be developed as originally planned.

"Thou Shalt not Smoke": Religion and smoking in a natural experiment of history.

We provide a new identification strategy to analyse the implications of religious affiliation on unhealthful behaviour by focusing on the link between religiousness and smoking. Our quasi-experimental research design exploits the exogenous dramatic fall in religious affiliation that took place in East Germany after the post-war separation. Our conditional difference-in-differences estimates on data from the German Socio-Economic Panel (SOEP) for the period 1998-2006 indicate that individuals who are not affiliated to any religious denomination are consistently 13-19 percentage points more likely to smoke than are religious individuals. We interpret our results on the basis of a restraining effect of religious ethics on unhealthy behaviour, confirming the view that religion is a far-reaching vehicle for the enforcement of social norms.