Cultural persistence and the 'herbal medicine paradox': Evidence from European data.

The use of herbal or traditional medicines has survived the proliferation of modern medicine. The phenomenon has been labeled as the 'herbal medicines paradox' (HMP). We study whether such HMP hypothesis can be explained by the persistence of attitudes across cultural boundaries. We undertake a secondary analysis of individual-level migration data to test the persistence of the use of herbal medicines in relation to norms in the person's country of birth (or home country). We study the association between attitudes towards herbal medicine treatments of both first (N = 3630) and second-generation (N = 1618) immigrants in 30 European countries, and the average attitudes of their sending country origins. We find robust evidence of an association that is stronger for the second-generation migrants. We document a stronger effect among maternal than paternal lineages, as well as significant heterogeneity based on migrants' country of origin. Our estimates are robust to different sample analysis. Our estimates are consistent with a cultural explanation for the HMP.

How to Use Quasi-Experimental Methods in Cardiovascular Research: A Review of Current Practice.

BACKGROUND: Quasi-experimental methods (QEMs) are a family of techniques used to estimate causal relationships when randomized controlled trials are unfeasible or unethical. They offer a powerful alternative to observational studies by introducing random assignment of individuals or groups into their design, thereby offering stronger means of establishing causation. The use of QEMs in cardiovascular research has not been systematically examined to determine steps toward improving and expanding their use. METHODS: We identified 4 main techniques using a systematic search strategy from 2016 to 2021: instrumental variable analysis, interrupted time series analysis, difference-in-differences analysis, and regression discontinuity designs. QEMs are examined as alternatives to randomized controlled trials and traditional observational studies; as more observational data becomes available to researchers, there are more opportunities to apply these techniques. Eligible articles were selected based on publication in high-ranked journals. The quality of eligible articles was appraised using the Joanna Briggs Institute checklist for quasi-experimental studies. RESULTS: Data from 380 studies were extracted based on our inclusion criteria. Forty-two of these studies were published in the top 10 medical or top 20 cardiovascular disease journals, and 25 studies were included after quality appraisal. The review identifies the main features and limitations associated with each technique, providing readers with practical guidance on how to apply these to their research. A graphical decision aid was developed to facilitate the routine use of QEMs. CONCLUSIONS: The use of QEMs in cardiovascular research published in contemporary, high-impact articles was examined. Findings are biased toward this segment of literature, which represents the latest developments in this growing area of cardiovascular research. The decision aid is a novel schematic that researchers can adopt into practice.

The labour market returns to sleep.

Despite the growing prevalence of insufficient sleep among individuals, we still know little about the labour market return to sleep. To address this gap, we use longitudinal data from Germany and leverage exogenous fluctuations in sleep duration caused by variations in time and local sunset times. Our findings reveal that a one-hour increase in weekly sleep is associated with a 1.6 percentage point rise in employment and a 3.4% increase in weekly earnings. Such effect on earnings stems from productivity improvements given that the number of working hours decreases with longer sleep duration. We also identify a key mechanism driving these effects, namely the enhanced mental well-being experienced by individuals who sleep longer hours.

Health inequality and health insurance coverage: The United States and China compared.

We study inequality in the distribution of self-assessed health (SAH) in the United States and China, two large countries that have expanded their insurance provisions in recent decades, but that lack universal coverage and differ in other social determinants of health. Using comparable health survey data from China and the United States, we compare health inequality trends throughout the period covering the public health insurance coverage expansions in the two countries. We find that whether SAH inequality is greater in the US or in China depends on the concept of status and the inequality-sensitivity parameter used; however, the regional pattern of SAH inequality is clearly associated with health-insurance coverage expansions in the US but not significant in China.

Is employment during motherhood a 'value changing experience'?

We study whether the experience of 'employment during motherhood' (EDM) exerts an effect on attitudes towards the welfare effects of EDM, which proxy gender norms with regards to employment. We examine unique evidence from a large, representative, and longitudinal data set that collects attitudinal data over about a decade in the United Kingdom. We draw on an instrumental variable (IV) strategy that exploits variation in local labour markets using a Bartik instrument for employment to address the potential endogeneity of EDM experience in explaining attitudes. We find that both childless women who work and mothers who do not work are more likely to agree with the statement that 'pre-school children suffer if their mothers work', which we interpret as more traditional gender values. However, this is not the case for women who work and have children. These findings suggest that motherhood confirms individuals' priors, and suggest that EDM is a value preserving rather than a value changing experience. These results suggest that the so-called 'motherhood penalty' in employment trajectories cannot be fully explained by a change in attitudes after giving birth.

Caregiving across generations: Do older adults with more grandchildren get another bite at the "sandwich" generation?

Understanding the influence of grandchildren on long-term care use is a growing issue. Indeed, many countries, middle-aged adults provide unpaid care for aging family members, often their parents, at home. Although the influence of adult children's availability on their aging parents' caregiving decisions has been widely studied, the influence of grandchildren remains largely unstudied. Parental time allocated to childcare may compete with elder care, necessitating paid home care or transfer to a nursing home. Alternatively, grandparents may provide childcare, increasing incentives to keep grandparents at home. Using data from the Survey of Health, Ageing and Retirement in Europe (75,296 observations from 11 countries covering years 2004-2018), we exploit an instrumental variable strategy to study the effect of grandchildren on grandparents' long-term care decisions, specifically, use of paid home care or transfer to a nursing home. We use the generosity of maternity leave policies in time and across countries as an instrumental variable to identify the effect of the number of grandchildren. We find that the presence of grandchildren significantly increases the likelihood of having grandparents live at home: the probability of paid home care significantly increases while the probability of nursing home admission falls significantly. In conclusion, policies influencing the number of grandchildren in families have an indirect impact on long-term care use trajectories, confirming that family policies and long-term care policies are strongly imbricated and should not be considered separately.

Mobility restrictions and alcohol use during lockdown: "A still and dry pandemic for the many"?

Unexpected mobility disruptions during lockdown during the first wave of COVID-19 became 'tipping points' with the potential to alter pre-pandemic routines sensitive to socialisation. This paper investigates the impact of lockdown exposure on alcohol consumption. We document two findings using information from the Google Mobility Report and longitudinal data from the Understanding Society survey (UKHLS) in the United Kingdom. First, we find a sharp reduction in both actual mobility and alcohol use (consistent with a "still and dry pandemic for the many" hypothesis). However, we document an increase in alcohol use among heavy drinkers, implying a split behavioural response to COVID-19 mobility restrictions based on alcohol use prior to the pandemic. Second, using the predictions of the prevalence-response elasticity theory, we find that the pandemic's reduction in social contacts is responsible for a 2.8 percentage point reduction in drinking among men.

How does exposure to COVID-19 influence health and income inequality aversion?

We study individual aversion to health and income inequality in three European countries (the United Kingdom, Germany, and Italy), its determinants and especially, the effects of exposure to three types of COVID-19 specific shocks affecting individuals' employment status, their income and health. Next, using evidence of representative samples of the population in the UK, we compare levels of health- and income-inequality aversion in the UK between the years 2016 and 2020. We document evidence of a significant increase in inequality aversion in both income and health domains. However, we show that inequality aversion is higher in the income domain than in the health domain. Furthermore, we find that inequality aversion in both domains increases in age and education and decreases in income and risk appetite. However, people directly exposed to major health shocks during the COVID-19 pandemic generally exhibited lower levels of aversion to both income and health inequality. Finally, we show that inequality aversion was significantly higher among those exposed to higher risk of COVID-19 mortality who experienced major health shocks during the pandemic. Supplementary Information: The online version contains supplementary material available at 10.1007/s00355-023-01460-8.

The social value of a SARS-CoV-2 vaccine: Willingness to pay estimates from four western countries.

SARS-CoV-2 vaccines give rise to positive externalities on population health, society and the economy in addition to protecting the health of vaccinated individuals. Hence, the social value of such a vaccine exceeds its market value. This paper estimates the willingness to pay (WTP) for a hypothetical SARS-CoV-2 vaccine (or shadow prices), in four countries, namely the United States (US), the United Kingdom, Spain and Italy during the first wave of the pandemic when COVID-19 vaccines were in development but not yet approved. WTP estimates are elicited using a payment card method to avoid "yea saying" biases, and we study the effect of protest responses, sample selection bias, as well as the influence of trust in government and risk exposure when estimating the WTP. Our estimates suggest evidence of an average value of a hypothetical vaccine of 100-200 US dollars once adjusted for purchasing power parity. Estimates are robust to a number of checks.

Negative energy balance hinders prosocial helping behavior.

The internal state of an animal, including homeostatic requirements, modulates its behavior. Negative energy balance stimulates hunger, thus promoting a range of actions aimed at obtaining food. While these survival actions are well established, the influence of the energy status on prosocial behavior remains unexplored. We developed a paradigm to assess helping behavior in which a free mouse was faced with a conspecific trapped in a restrainer. We measured the willingness of the free mouse to liberate the confined mouse under diverse metabolic conditions. Around 42% of ad libitum-fed mice exhibited a helping behavior, as evidenced by the reduction in the latencies to release the trapped cagemate. This behavior was independent of subsequent social contact reward and was associated with changes in corticosterone indicative of emotional contagion. This decision-making process was coupled with reduced blood glucose excursions and higher Adenosine triphosphate (ATP):Adenosine diphosphate (ADP) ratios in the forebrain of helper mice, suggesting that it was a highly energy-demanding process. Interestingly, chronic (food restriction and type 2 diabetes) and acute (chemogenetic activation of hunger-promoting AgRP neurons) situations mimicking organismal negative energy balance and enhanced appetite attenuated helping behavior toward a distressed conspecific. To investigate similar effects in humans, we estimated the influence of glycated hemoglobin (a surrogate of long-term glycemic control) on prosocial behavior (namely charity donation) using the Understanding Society dataset. Our results evidenced that organismal energy status markedly influences helping behavior and that hypothalamic AgRP neurons are at the interface of metabolism and prosocial behavior.

Is the use of IVF add-on treatments driven by patients or clinics? Findings from a UK patient survey.

There are conflicting narratives over what drives demand for add-ons. We undertook an online survey of IVF patients to determine whether patients perceive that use of IVF add-ons is driven by patients or practitioners. People who underwent IVF in the UK in the previous five years were recruited via social media Survey questions focussed on the roles of clinician offer and patient request, including who first suggested use of add-ons in IVF consultations, where patients first heard about them, and which information sources they trusted. From a total of 261 responses, 224 met the inclusion criteria. Overall, 67% of respondents had used one or more IVF add-ons, most commonly: time-lapse imaging (27%), EmbryoGlue (27%), and endometrial scratching (26%). Overall, 81% of the add-ons used were offered to participants by clinicians (compared to 19% requested by themselves). Half (54%) reported being offered add-ons during consultations, compared to 24% who initiated discussion about add-ons. Higher proportions of private patients reported being offered (90%), requesting (47%) and using (74%) add-ons than those with NHS funding (74%, 29%, 52%, respectively). The main limitations of this study are the small sample size, recruitment via a convenience sample, and the self-reported data capture which is subject to recall bias.

Trusting the Health System and COVID 19 Restriction Compliance.

We examine the extent to which exposure to higher relative COVID-19 mortality (RM), influences health system trust (HST), and whether changes in HST explain the perceived ease of compliance with pandemic restrictions during the COVID-19 pandemic. Drawing on evidence from two representative surveys covering all regions of 28 European countries before and after the first COVID-19 wave, and using a difference in differences strategy together with Coarsened Exact Matching (CEM), we document that living in a region with higher RM during the first wave of the pandemic increased HST. However, the positive effect of RM on HST is driven by individuals over 45 years of age, and the opposite effect is found among younger cohorts. Furthemore, we find that a higher HST reduces the costs of complying with COVID-19 restrictions, but only so long as excess mortality does not exceed the average by more than 20%, at which point the ease of complying with COVID-19 restrictions significantly declines, offsetting the positive effect of trust in the healthcare system. Our interpretation of these estimates is that a higher RM is interpreted as a risk signal among those over 45, and as a signal of health-care system failure among younger age individuals.

The institutional origins of vaccines distrust: Evidence from former-Soviet countries.

How is vaccines scepticism related to the exposure to Soviet communism? Using individual level evidence on vaccine trust with regards to its efficiency and safety in 122 countries that differ in their exposure to communism, we document that past exposure to Soviet communism is associated with lower trust in vaccination. We show that exposure to socio-political regimes can negatively affect trust in vaccines, which is explained by weak trust in both government and medical advice from doctors as well as in people from the neighbourhood. These results suggest that roots of vaccine scepticism lie in a wider distrust in public and state institutions resulting from the exposure to Soviet communism.

'Investing' in care for old age? An examination of long-term care expenditure dynamics and its spillovers.

We study the dynamic drivers of expenditure on long-term care (LTC) programmes, and more specifically, the effects of labour market participation of traditional unpaid caregivers (women aged 40 and older) on LTC spending, alongside the spillover effects of a rise in LTC expenditure on health care expenditures (HCE) and the economy (per capita GDP). Our estimates draw from a panel of more than a decade worth of expenditure data from a sample of OECD countries. We use a panel vector auto-regressive (panel-VAR) system that considers the dynamics between the dependent variables. We find that LTC expenditure increases with the rise of the labour market participation of the traditional unpaid caregiver (women over 40 years of age), and that such expenditures rise exerts large spillover effects on health spending and the economy. We find that a 1% increase in female labour participation gives rise to a 1.48% increase in LTC expenditure and a 0.88% reduction in HCE. The effect of LTC spending over HCE is mainly driven by a reduction in inpatient and medicine expenditures, exhibiting large country heterogeneity. Finally, we document significant spillover effects of LTC expenditures on per capita GDP. Supplementary Information: The online version contains supplementary material available at 10.1007/s00181-022-02246-0.

Preterm birth and educational disadvantage: Heterogeneous effects.

Although preterm birth is the leading cause of perinatal morbidity and mortality in advanced economies, evidence about the consequences of prematurity in later life is limited. Using Swedish registers for cohorts born 1982-94 (N  =  1,087,750), we examine the effects of preterm birth on school grades at age 16 using sibling fixed effects models. We further examine how school grades are affected by degree of prematurity and the compensating roles of family socio-economic resources and characteristics of school districts. Our results show that the negative effects of preterm birth are observed mostly among children born extremely preterm (<28 weeks); children born moderately preterm (32-<37 weeks) suffer no ill effects. We do not find any evidence for a moderating effect of parental socio-economic resources. Children born extremely preterm and in the top decile of school districts achieve as good grades as children born at full term in an average school district.Supplementary material for this article is available at: http://dx.doi.org/10.1080/00324728.2022.2080247.

The 'welcomed lockdown' hypothesis? Mental wellbeing and mobility restrictions.

The COVID-19 pandemic and its mobility restrictions have been an external shock, influencing mental wellbeing. However, does risk exposure to COVID-19 affect the mental wellbeing effect of lockdowns? This paper examines the 'welcomed lockdown' hypothesis, namely the extent to which there is a level of risk where mobility restrictions are not a hindrance to mental wellbeing. We exploit the differential timing of exposure the pandemic, and the different stringency of lockdown policies across European countries and we focus on the effects on two mental health conditions, namely anxiety and depression. We study whether differences in the individual symptoms of anxiety and depression are explained by the combination of pandemic mortality and stringency of lockdown. We draw on an event study approach, complemented with a Difference-in-Difference (DiD), and Regression Discontinuity Design (RDD). Our estimates suggest an average increase in depression (3.95%) and anxiety (10%) symptoms relative to the mean level on the day that lockdown took effect. However, such effects are wiped out when a country's exhibits high mortality ('pandemic category 5'). Hence, we conclude that in an environment of high mortality, lockdowns no longer give rise to a reduction in mental wellbeing consistent with the 'welcome lockdown' hypothesis.

Risky restrictions? Mobility restriction effects on risk awareness and anxiety.

Although mobility restrictions during the COVID-19 pandemic were intended to change behaviours by influencing risk awareness, they might have prompted a rise in risk anxiety ('worry for one's health') both among individuals exposed to such restrictions and those living in border countries. This paper studies this question by examining survey data from 22 European countries in the first wave of the COVID-19 pandemic (March 20th and April 6th 2020). Drawing on an event study analysis we show that COVID-19 mobility restrictions raised individuals COVID-19 risk awareness both in the exposed and border countries for almost a week after the announcement. The spillover effect on border countries accounts for about 67% of the effect in the exposed country. However, mobility restrictions gave rise to an increase in  risk anxiety in low-risk countries (which is between 4 and 7 times higher than moderate and high-risk countries). These effects are heterogeneous across age, education and socioeconomic status.

Too Healthy to Fall Sick? Longevity Expectations and Protective Health Behaviours during the First Wave of COVID-19.

Longevity expectations (LE) are subjective assessments of future health status that can influence a number of individual health protective decisions. This is especially true during a pandemic such as COVID-19, as the risk of ill health depends more than ever on such protective decisions. This paper examines the causal effect of LE on some protective health behaviors and a number of decisions regarding forgoing health care using individual differences in LE. We use data from the Survey of Health Ageing and Retirement in Europe, and we draw on an instrumental variable strategy exploiting individual level information on parental age at death. Consistent with the too healthy to be sick hypothesis, we find that individuals, exhibiting higher expected longevity, are more likely to engage in protective behaviours, and are less likely to forgo medical treatment. We estimate that a one standard deviation increase in LE increases the probability to comply always with social distancing by 0.6%, to meet people less often by 0.4% and decreases the probability to forgo any medical treatment by 0.6%. Our estimates vary depending on supply side restrictions influencing the availability of health care, as well as individual characteristics such as their gender and the presence of pre-existing health conditions.

When do persuasive messages on vaccine safety steer COVID-19 vaccine acceptance and recommendations? Behavioural insights from a randomised controlled experiment in Malaysia.

INTRODUCTION: Vaccine safety is a primary concern among vaccine-hesitant individuals. We examined how seven persuasive messages with different frames, all focusing on vaccine safety, influenced Malaysians to accept the COVID-19 vaccine, and recommend it to individuals with different health and age profiles; that is, healthy adults, the elderly, and people with pre-existing health conditions. METHODS: A randomised controlled experiment was conducted from 29 April to 7 June 2021, which coincided with the early phases of the national vaccination programme when vaccine uptake data were largely unavailable. 5784 Malaysians were randomly allocated into 14 experimental arms and exposed to one or two messages that promoted COVID-19 vaccination. Interventional messages were applied alone or in combination and compared against a control message. Outcome measures were assessed as intent to both take the vaccine and recommend it to healthy adults, the elderly, and people with pre-existing health conditions, before and after message exposure. Changes in intent were modelled and we estimated the average marginal effects based on changes in the predicted probability of responding with a positive intent for each of the four outcomes. RESULTS: We found that persuasive communication via several of the experimented messages improved recommendation intentions to people with pre-existing health conditions, with improvements ranging from 4 to 8 percentage points. In contrast, none of the messages neither significantly improved vaccination intentions, nor recommendations to healthy adults and the elderly. Instead, we found evidence suggestive of backfiring among certain outcomes with messages using negative attribute frames, risky choice frames, and priming descriptive norms. CONCLUSION: Message frames that briefly communicate verbatim facts and stimulate rational thinking regarding vaccine safety may be ineffective at positively influencing vaccine-hesitant individuals. Messages intended to promote recommendations of novel health interventions to people with pre-existing health conditions should incorporate safety dimensions. TRIAL REGISTRATION NUMBER: NCT05244356.

Do Public Caregiving Subsidies and Supports affect the Provision of Care and Transfers?

We study whether caregiving and intergenerational transfer decisions are sensitive to changes in economic incentives following the inception of a new unconditional and universal system of allowances and supports, after the introduction of the 2006 Promotion of Personal Autonomy and Care for Dependent Persons Act (SAAD in Spanish), and the ensuing effects of its austerity cuts after 2012. We find that whilst the introduction of a caregiving allowance (of a maximum value of €530 in 2011) increased the supply of informal caregiving by 20-22 percentual points (pp), the inception of a companion system of publicly subsidised homecare supports did not modify the supply of care. Consistent with an exchange motive for intergenerational transfers, we estimate an average 17 pp (8.2-8.7pp) increase (decrease) in downstream (upstream) transfers among those receiving caregiving allowances. Our estimates resulting from the reduction in the allowances and supports after the austerity cuts in 2012 are consistent with our main estimates, and suggest stronguer effects among lower-income families.