Unveiling the health consequences of air pollution in the world's most polluted nations

Air pollution poses a persuasive threat to global health, demonstrating widespread detrimental effects on populations worldwide. Exposure to pollutants, notably particulate matter with a diameter of 2.5 µm (PM2.5), has been unequivocally linked to a spectrum of adverse health outcomes. A nuanced understanding of the relationship between them is crucial for implementing effective policies. This study employs a comprehensive investigation, utilizing the extended health production function framework alongside the system generalized method of moments (SGMM) technique, to scrutinize the interplay between air pollution and health outcomes. Focusing on a panel of the top twenty polluted nations from 2000 to 2021, the findings yield substantial insights. Notably, PM2.5 concentration emerges as a significant factor, correlating with a reduction in life expectancy by 3.69 years and an increase in infant mortality rates by 0.294%. Urbanization is found to increase life expectancy by 0.083 years while concurrently decreasing infant mortality rates by 0.00022%. An increase in real per capita gross domestic product corresponds with an improvement in life expectancy by 0.21 years and a decrease in infant mortality rates by 0.00065%. Similarly, an elevated school enrollment rate is associated with a rise in life expectancy by 0.17 years and a decline in infant mortality rates by 0.00032%. However, a higher population growth rate is found to modestly decrease life expectancy by 0.019 years and slightly elevate infant mortality rates by 0.000016%. The analysis reveals that per capita greenhouse gas emissions exert a negative impact, diminishing life expectancy by 0.486 years and elevating infant mortality rates by 0.00061%, while per capita energy consumption marginally reduces life expectancy by 0.026 years and increases infant mortality rates by 0.00004%. Additionally, economic volatility shock presents a notable decrement in life expectancy by 0.041 years and an increase in infant mortality rates by 0.000045%, with inflationary shock further exacerbating adverse health outcomes by lowering life expectancy by 0.70 years and elevating infant mortality rates by 0.00025%. Moreover, the study scrutinizes the role of institutional quality, revealing a constructive impact on health outcomes. Specifically, the institutional quality index is associated with an increase in life expectancy by 0.66% and a decrease in infant mortality rates by 0.0006%. Extending the analysis to examine the nuanced dimensions of institutional quality, the findings discern that economic institutions wield a notably stronger positive influence on health outcomes compared to political and institutional governance indices. Finally, the results underscore the pivotal moderating role of institutional quality in mitigating the deleterious impact of PM2.5 concentration on health outcomes, counterbalancing the influence of external shocks, and improving the relationships between explanatory variables and health outcome indicators. These findings offer critical insights for guiding evidence-based policy implications, with a focus on fostering resilient, sustainable, and health-conscious societies.

Time trends in self-reported depressive symptoms, prescription of antidepressants, sedatives and hypnotics and the emergence of social media among Norwegian adolescents

BACKGROUND

Research has shown increased mental health problems and use of prescription drugs among adolescents in recent years and social media use has been linked to poorer mental health. However, trend studies concerning these topics are scarce. The purpose of this study was to analyze gender-specific trends in a) symptoms of depression and loneliness, and b) prescription of antidepressants, hypnotics and sedatives, in relation to the emergence of social media among adolescents in Norway.

METHODS

This is an ecological study using data from the 'Young in Oslo' surveys from 1996 to 2021. The surveys included approximately 110 000 students, 14-17 years of age, and yielded a response rate varying from 95% in 1996 to 64% in 2021. A self-report questionnaire was used to collect information on symptoms of depression and loneliness. Information on antidepressant and sleep medication prescription was retrieved from the Norwegian Prescription Database for the age group 15 to 19 years. A graphical approach and logistic regression models were used to examine gender-specific time-trends between 1996 to 2021.

RESULTS

We found a doubling in self-reported symptoms of depression and loneliness among girls between 1996 and 2021, with the steepest increase in the period from 2006 to 2012, when Facebook and other social media were introduced. A similar trend was observed in the prescription of antidepressants among girls, with the steepest increase between 2011 and 2013. Among both boys and girls, 'worried too much about things' and 'had sleep problems' were the two symptoms with the greatest changes.

CONCLUSION

A significant upward trend in self-reported depressive symptoms and medication use was observed over the past 25 years, with variations in the rate of increase, including a steeper trajectory during certain periods immediately after the introduction of social media platforms in Norway.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study

BACKGROUND

Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest.

METHODS

DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries.

RESULTS

Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low.

CONCLUSIONS

The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Have COVID-19 Stimulus Packages Mitigated the Negative Health Impacts of Pandemic-Related Job Losses? A Systematic Review of Global Evidence from the First Year of the Pandemic

Social protection can buffer the negative impacts of unemployment on health. Have stimulus packages introduced during the COVID-19 pandemic mitigated potential harms to health from unemployment? We performed a systematic review of the health effects of job loss during the first year of the pandemic. We searched three electronic databases and identified 49 studies for inclusion. Three United States-based studies found that stimulus programs mitigated the impact of job loss on food security and mental health. Furloughs additionally appeared to reduce negative impacts when they were paid. However, despite the implementation of large-scale stimulus packages to reduce economic harms, we observed a clear pattern that job losses were nevertheless significantly associated with negative impacts, particularly on mental health, quality of life, and food security. We also observe suggestive evidence that COVID-related job loss was associated with child maltreatment, worsening dental health, and poor chronic disease outcomes. Overall, although we did find evidence that income-support policies appeared to help protect people from the negative health consequences of pandemic-related job loss, they were not sufficient to fully offset the threats to health. Future research should ascertain how to ensure adequate access to and generosity of social protection programs during epidemics and economic downturns.

Changing Epidemiology of Tinea Capitis in Athens, Greece: The Impact of Immigration and Review of Literature

Mass population movements have altered the epidemiology of tinea capitis (TC) in countries receiving refugees. Periodic monitoring of the local pathogen profiles may serve as a basis for both the selection of appropriate empirical antifungal therapy and the implementation of preventive actions. Therefore, we investigated the impact of an unprecedented immigration wave occurring in Greece since 2015 on the epidemiological trends of TC. All microbiologically confirmed TC cases diagnosed during the period 2012-2019 in a referral academic hospital for dermatological disorders in Athens, Greece, were retrospectively reviewed. A total of 583 patients were recorded, where 348 (60%) were male, 547 (94%) were children and 160 (27%) were immigrants from Balkan, Middle Eastern, Asian as well as African countries. The overall annual incidence of TC was 0.49, with a significant increase over the years (p = 0.007). M. canis was the predominant causative agent (74%), followed by T. violaceum (12%), T. tonsurans (7%) and other rare dermatophyte species (7%). M. canis prevalence decreased from 2014 to 2019 (84% to 67%, p = 0.021) in parallel with a three-fold increase in T. violaceum plus T. tonsurans rates (10% to 32%, p = 0.002). An increasing incidence of TC with a shift towards anthropophilic Trichophyton spp. in Greece could be linked to the immigration flows from different socioeconomic backgrounds.

Ethnic-Regional Differences in the Allocation of High Complexity Spending in Brazil: Time Analysis 2010-2019

The following paper presents as a research problem the ethnic-regional differences in the allocation of high complexity spending in Brazil in an analysis from 2010 to 2019. This is a descriptive research in which a generalized linear model (GLM) was developed to analyze these hospital expenditures with high complexity procedures. The total spending on high complexity procedures in Brazil has increased over the past decade. The study shows that the lowest average expenditures are found in the North and Northeast regions. When comparing the spending between different ethnicities, it was observed that the only decrease between the years 2010 and 2019 was in the amount spent on procedures in indigenous people. The spending on male patients was significantly higher compared to female patients. The highest expenditures, on the other hand, are concentrated in the regions of state capitals favoring the strengthening of hub municipalities. Geographic inequalities in access still persist, even with most states already offering almost all procedures. The Brazilian territory is very heterogeneous and needs to organize its health system by regions, therefore integrated public policies and economic and social development are urgently needed.

Nonpharmaceutical interventions reduce the incidence and mortality of COVID‐19: A study based on the survey from the International COVID‐19 Research Network (ICRN)

The recently emerged novel coronavirus, “severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2),” caused a highly contagious disease called coronavirus disease 2019 (COVID‐19). It has severely damaged the world's most developed countries and has turned into a major threat for low‐ and middle‐income countries. Since its emergence in late 2019, medical interventions have been substantial, and most countries relied on public health measures collectively known as nonpharmaceutical interventions (NPIs). We aimed to centralize the accumulative knowledge of NPIs against COVID‐19 for each country under one worldwide consortium. International COVID‐19 Research Network collaborators developed a cross‐sectional online survey to assess the implications of NPIs and sanitary supply on the incidence and mortality of COVID‐19. The survey was conducted between January 1 and February 1, 2021, and participants from 92 countries/territories completed it. The association between NPIs, sanitation supplies, and incidence and mortality were examined by multivariate regression, with the log‐transformed value of population as an offset value. The majority of countries/territories applied several preventive strategies, including social distancing (100.0%), quarantine (100.0%), isolation (98.9%), and school closure (97.8%). Individual‐level preventive measures such as personal hygiene (100.0%) and wearing facial masks (94.6% at hospitals; 93.5% at mass transportation; 91.3% in mass gathering facilities) were also frequently applied. Quarantine at a designated place was negatively associated with incidence and mortality compared to home quarantine. Isolation at a designated place was also associated with reduced mortality compared to home isolation. Recommendations to use sanitizer for personal hygiene reduced incidence compared to the recommendation to use soap. Deprivation of masks was associated with increased incidence. Higher incidence and mortality were found in countries/territories with higher economic levels. Mask deprivation was pervasive regardless of economic level. NPIs against COVID‐19 such as using sanitizer, quarantine, and isolation can decrease the incidence and mortality of COVID‐19.

Nonpharmaceutical interventions reduce the incidence and mortality of COVID-19: A study based on the survey from the International COVID-19 Research Network (ICRN)

The recently emerged novel coronavirus, "severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)," caused a highly contagious disease called coronavirus disease 2019 (COVID-19). It has severely damaged the world's most developed countries and has turned into a major threat for low- and middle-income countries. Since its emergence in late 2019, medical interventions have been substantial, and most countries relied on public health measures collectively known as nonpharmaceutical interventions (NPIs). We aimed to centralize the accumulative knowledge of NPIs against COVID-19 for each country under one worldwide consortium. International COVID-19 Research Network collaborators developed a cross-sectional online survey to assess the implications of NPIs and sanitary supply on the incidence and mortality of COVID-19. The survey was conducted between January 1 and February 1, 2021, and participants from 92 countries/territories completed it. The association between NPIs, sanitation supplies, and incidence and mortality were examined by multivariate regression, with the log-transformed value of population as an offset value. The majority of countries/territories applied several preventive strategies, including social distancing (100.0%), quarantine (100.0%), isolation (98.9%), and school closure (97.8%). Individual-level preventive measures such as personal hygiene (100.0%) and wearing facial masks (94.6% at hospitals; 93.5% at mass transportation; 91.3% in mass gathering facilities) were also frequently applied. Quarantine at a designated place was negatively associated with incidence and mortality compared to home quarantine. Isolation at a designated place was also associated with reduced mortality compared to home isolation. Recommendations to use sanitizer for personal hygiene reduced incidence compared to the recommendation to use soap. Deprivation of masks was associated with increased incidence. Higher incidence and mortality were found in countries/territories with higher economic levels. Mask deprivation was pervasive regardless of economic level. NPIs against COVID-19 such as using sanitizer, quarantine, and isolation can decrease the incidence and mortality of COVID-19.

The COVID-19 System Shock Framework: Capturing Health System Innovation During the COVID-19 Pandemic

BACKGROUND

Coronavirus disease 2019 (COVID-19) has resulted in over 2 million deaths globally. The experience in Australia presents an opportunity to study contrasting responses to the COVID-19 health system shock. We adapted the Hanefeld et al framework for health systems shocks to create the COVID-19 System Shock Framework (CSSF). This framework enabled us to assess innovations and changes created through COVID-19 at the Sydney Children's Hospitals Network (SCHN), the largest provider of children's health services in the Southern hemisphere.

METHODS

We used ethnographic methods, guided by the CSSF, to map innovations and initiatives implemented across SCHN during the pandemic. An embedded field researcher shadowed members of the emergency operations centre (EOC) for nine months. We also reviewed clinic and policy documents pertinent to SCHN's response to COVID-19 and conducted interviews and focus groups with stakeholders, including clinical directors, project managers, frontline clinicians, and other personnel involved in implementing innovations across SCHN.

RESULTS

The CSSF captured SCHN's complex response to the pandemic. Responses included a COVID-19 assessment clinic, inpatient and infectious disease management services, redeploying and managing a workforce working from home, cohesive communication initiatives, and remote delivery of care, all enabled by a dedicated COVID-19 fund. The health system values that shaped SCHN's response to the pandemic included principles of equity of healthcare delivery, holistic and integrated models of care, and supporting workforce wellbeing. SCHN's resilience was enabled by innovation fostered through a non-hierarchical governance structure and responsiveness to emerging challenges balanced with a singular vision.

CONCLUSION

Using the CSSF, we found that SCHN's ability to innovate was key to ensuring its resilience during the pandemic.

Have Deaths of Despair Risen during the COVID-19 Pandemic? A Systematic Review

This systematic review synthesized literature on potential impacts of protracted isolation and other disruptions during the COVID-19 pandemic on deaths of despair (suicide, overdoses, and drug-related liver diseases). Five electronic databases were searched yielding 70 eligible articles. Extant evidence mostly from high-income countries indicates COVID-19-related disruption may not have influenced suicide rates so far, but there have been reports of increased drug-related and liver disease mortality. Minority groups and women were more vulnerable, indicating the need for stronger equity focus on pandemic recovery and resilience strategies. Further high-quality studies with longer-term follow-up, especially from low-income countries, will inform these strategies.

Early-life exposure to economic stress and metabolic risks in young adulthood: the children of the reunification in East Germany

BACKGROUND

Research on the long-term health consequences of early-life exposure to economic crises is scarce. We examine for the first time the long-term effects of early-life exposure to an economic crisis on metabolic health risks. We study objective health measures, and exploit the quasi-experimental situation of the postreunification economic crisis in East Germany.

METHODS

Data were drawn from two waves of the longitudinal German Health Interview and Examination Survey for Children and Adolescents (2003-2006, 2014-2017). We compared 392 East Germans who were exposed to the economic crisis in utero and at ages 0-5 with 1123 of their West German counterparts using propensity score matching on individual and family characteristics. We assessed blood pressure, cholesterol, blood fat and body mass index (BMI); both combined as above-average metabolic health risks and individually at ages 19-30.

RESULTS

Early-life exposure to the economic crisis significantly increased the number of above-average metabolic health risks in young adulthood by 0.1482 (95% CI 0.0169 to 0.2796), which was 5.8% higher compared with no exposure. Among individuals exposed in utero, only females showed significant effects. Early-life exposure to the economic crisis was associated with increased systolic (0.9969, 95% CI -0.2806 to 2.2743) and diastolic blood pressure (0.6786, 95% CI -0.0802 to 1.4373), and with increased BMI (0.0245, 95% CI -0.6516 to 0.7001).

CONCLUSION

The increased metabolic health risks found for women exposed to the postreunification economic crisis in-utero are likely attributable to increased economic stress. While the observed differences are small, they may foreshadow the emergence of greater health disparities in older age.

Medication use in populations exposed to the 2010 Eyjafjallajökull eruption: an interrupted time series analysis

OBJECTIVES

To assess the trends in medication use indicative of physical and psychological morbidity following the 2010 volcanic eruption in Eyjafjallajökull immediately after and during a 3-year period following the eruption.

DESIGN

Population-based register study.

SETTING

Eyjafjallajökull eruption in Iceland, 2007-2013.

PARTICIPANTS

All residents in Iceland who received at least one medication dispensing were identified. Residents of exposed areas were classified into exposure groups (individual-level data) and residents in other parts of Iceland were included as a non-exposed group (aggregated data).

INTERVENTION/EXPOSURE

Eyjafjallajökull erupted on 14 April 2010 and continued for 39 days, producing heavy ash fall in South Iceland.

MAIN OUTCOME MEASURES

Using interrupted time series analysis, we examined annual and quarterly changes in medicine use, measured as number of dispensed defined daily dose (DDD) per 1000 individuals. We calculated the level shift (immediate change) and change in slope from pre-eruption to post-eruption (long-term change) in medication dispensing.

RESULTS

Among exposed residents, there was a 6% decrease (95% CI -7% to -4%) in the annual number of dispensed DDDs 1-year post-eruption in the overall medication class, including analgesics (-5%, 95% CI -6% to -3%), hypnotics and sedatives (-9%, 95% CI -11% to -7%) and respiratory medications (-7%, 95% CI -9% to -5%; -8%, 95% CI -11% to -4%). Simultaneously, there was a 9% decrease (95% CI -14% to -4%) in the overall medication class among non-exposed residents. Moreover, among exposed residents, we observed change in slope of -4% (95% CI -7% to -1%) in the overall medication class, including for analgesics (-6%, 95% CI -8% to -3%) and other respiratory drugs (-10%, 95% CI -16% to -4%).

CONCLUSION

Our findings indicate that the eruption did not lead to increases in medication dispensing among residents of exposed areas, rather decreases for some medicine classes. The results should be interpreted with caution since the content of each eruption differs.

Economic change and population health: lessons learnt from an umbrella review on the Great Recession

OBJECTIVES

Worldwide, the COVID-19 pandemic triggered the sharpest economic downturn since the Great Recession. To prepare for future crises and to preserve public health, we conduct an overview of systematic reviews to examine the evidence on the effect of the Great Recession on population health.

METHODS

We searched PubMed and Scopus for systematic reviews and/or meta-analyses focusing specifically on the impact of the Great Recession on population health (eg, mental health). Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed throughout this review and critical appraisal of included systematic reviews was performed using Assessing the Methodological Quality of Systematic Reviews.

RESULTS

Twenty-one studies were identified and consistently showed that the Great Recession was most risky to health, the more a country's economy was affected and the longer strict austerity policies were in place. Consequently, a deterioration of health was highest in countries that had implemented strict austerity measures (eg, Greece), but not in countries that rejected austerity measures (eg, Germany). Moreover, the impact of the Great Recession fell disproportionately on the most vulnerable groups such as people in unemployment, at risk of unemployment and those living in poverty.

CONCLUSIONS

The experiences of the last economic crisis show that it is possible to limit the consequences for health. Prioritising mental healthcare and prevention, foregoing austerity measures in the healthcare system and protecting vulnerable groups are the most important lessons learnt. Moreover, given the further aggravating social inequalities, a health in all policies approach, based on a comprehensive Health Impact Assessment, is advised.

Increase in Mental Disorders During the COVID-19 Pandemic-The Role of Occupational and Financial Strains

BACKGROUND

Numerous studies have reported an increase in mental disorders during the COVID-19 pandemic, but the exact reasons for this development are not well understood. In this study we investigate whether pandemic-related occupational and financial changes (e.g., reduced working hours, working from home, financial losses) were associated with increased symptoms of depression and anxiety compared with the situation before the pandemic.

METHODS

We analyzed data from the German National Cohort (NAKO) Study. Between May and November 2020, 161 849 study participants answered questions on their mental state and social circumstances. Their responses were compared with data from the baseline survey before the pandemic (2014-2019). Linear fixed-effects models were used to determine whether individual changes in the severity of symptoms of depression (PHQ-9) or anxiety (GAD-7) were associated with occupational/ financial changes (controlling for various covariates).

RESULTS

The prevalence of moderate or severe symptoms of depression and anxiety increased by 2.4% and 1.5%, respectively, during the COVID-19 pandemic compared with the preceding years. The mean severity of the symptoms rose slightly. A pronounced increase in symptoms was observed among those who became unemployed during the pandemic (+ 1.16 points on the depression scale, 95% confidence interval [0.91; 1.41], range 0-27). Increases were also seen for reduced working hours with no short-time allowance, increased working hours, working from home, insecurity regarding employment, and financial strain. The deterioration in mental health was largely statistically explained by the occupational and financial changes investigated in the model.

CONCLUSION

Depressive symptoms and anxiety disorders increased slightly in the study population during the first year of the COVID-19 pandemic. Occupational and financial difficulties were an essential contributory factor. These strains should be taken into account both in the care of individual patients and in the planning of targeted prevention measures.

Asian American/Pacific Islander and Hispanic Ethnic Enclaves, Neighborhood Socioeconomic Status, and Hepatocellular Carcinoma Incidence in California: An Update

BACKGROUND

Using more recent cancer registry data, we analyzed disparities in hepatocellular carcinoma (HCC) incidence by ethnic enclave and neighborhood socioeconomic status (nSES) among Asian American/Pacific Islander (AAPI) and Hispanic populations in California.

METHODS

Primary, invasive HCC cases were identified from the California Cancer Registry during 1988-1992, 1998-2002, and 2008-2012. Age-adjusted incidence rates (per 100,000 population), incidence rate ratios, and corresponding 95% confidence intervals were calculated for AAPI or Hispanic enclave, nSES, and the joint effects of ethnic enclave and nSES by time period (and the combination of the three periods), sex, and race/ethnicity.

RESULTS

In the combined time period, HCC risk increased 25% for highest versus lowest quintile of AAPI enclave among AAPI males. HCC risk increased 22% and 56% for lowest versus highest quintile of nSES among AAPI females and males, respectively. In joint analysis, AAPI males living in low nSES areas irrespective of enclave status were at 17% to 43% increased HCC risk compared with AAPI males living in areas of nonenclave/high nSES. HCC risk increased by 22% for Hispanic females living in areas of low nSES irrespective of enclave status and by 19% for Hispanic males living in areas of nonenclave/low nSES compared with their counterparts living in areas of nonenclave/high nSES.

CONCLUSIONS

We found significant variation in HCC incidence by ethnic enclave and nSES among AAPI and Hispanic populations in California by sex and time period.

IMPACT

Future studies should explore how specific attributes of enclaves and nSES impact HCC risk for AAPI and Hispanic populations.

Increasing Incidence and Shifting Epidemiology of Candidemia in Greece: Results from the First Nationwide 10-Year Survey

Globally, candidemia displays geographical variety in terms of epidemiology and incidence. In that respect, a nationwide Greek study was conducted, reporting the epidemiology of Candida bloodstream infections and susceptibility of isolates to antifungal agents providing evidence for empirical treatment. All microbiologically confirmed candidemia cases in patients hospitalized in 28 Greek centres during the period 2009–2018 were recorded. The study evaluated the incidence of infection/100,000 inhabitants, species distribution, and antifungal susceptibilities of isolated strains. Overall, 6057 candidemic episodes occurred during the study period, with 3% of them being mixed candidemias. The average annual incidence was 5.56/100,000 inhabitants, with significant increase over the years (p = 0.0002). C. parapsilosis species complex (SC) was the predominant causative agent (41%), followed by C. albicans (37%), C. glabrata SC (10%), C. tropicalis (7%), C. krusei (1%), and other rare Candida spp. (4%). C. albicans rates decreased from 2009 to 2018 (48% to 31%) in parallel with a doubling incidence of C. parapsilosis SC rates (28% to 49%, p < 0.0001). Resistance to amphotericin B and flucytosine was not observed. Resistance to fluconazole was detected in 20% of C. parapsilosis SC isolates, with a 4% of them being pan-azole-resistant. A considerable rising rate of resistance to this agent was observed over the study period (p < 0.0001). Echinocandin resistance was found in 3% of C. glabrata SC isolates, with 70% of them being pan-echinocandin-resistant. Resistance rate to this agent was stable over the study period. This is the first multicentre nationwide study demonstrating an increasing incidence of candidemia in Greece with a species shift toward C. parapsilosis SC. Although the overall antifungal resistance rates remain relatively low, fluconazole-resistant C. parapsilosis SC raises concern.

Economic Recession and the Long Term Risk of Psychiatric Disorders and Alcohol Related Diseases-A Cohort Study From Eastern Finland

BACKGROUND

Long-term development of psychiatric disorders and alcohol-related diseases after economic recessions is insufficiently studied. We investigated the overall impact of the economic recession between 1991 and 1994 in Finland on the long-term incidence of psychiatric and alcohol-related diseases.

METHODS

A population-based sample of 1,774 women and men aged 53-73 years were examined between 1998 and 2001 from the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD). Participants completed comprehensive questionnaires on the possible impact of the 1990s recession in Finland on their lives. They were followed-up until 2018. Cox proportional hazards regression was used to estimate hazard ratios (HR) of new incident psychiatric and alcohol-related disorders during the 20-years follow-up after linkage to the National Hospital Registry. Logistic regression was used to estimate odds ratios (OR) of psychiatric disorders at baseline.

RESULTS

At baseline, 93 participants had psychiatric disorders. During 20-years follow-up, 138 new psychiatric disorders and 45 alcohol-related diseases were developed. The covariate-adjusted risk of psychiatric disorders was over twice higher among men who experienced recession-induced hardships compared to those who did not (HR = 2.20, 95%CI = 1.04-4.70, p = 0.04). The risk of alcohol-related diseases was more than four times higher among men with hardships (HR = 4.44, 95%CI = 1.04-18.90, p = 0.04). No such associations were observed among women. No association was observed between recession-induced hardships and having psychiatric disorders at baseline in both genders (multivariate-adjusted p = 0.63 for women, multivariate-adjusted p = 0.36 for men).

CONCLUSION

Long-term risk of psychiatric disorders and alcohol-related diseases was increased after the 1990s economic recession in Finland, but only among middle-age and older men.

Associations between COVID-19 mobility restrictions and economic, mental health, and suicide-related concerns in the US using cellular phone GPS and Google search volume data

During the COVID-19 pandemic, US populations have experienced elevated rates of financial and psychological distress that could lead to increases in suicide rates. Rapid ongoing mental health monitoring is critical for early intervention, especially in regions most affected by the pandemic, yet traditional surveillance data are available only after long lags. Novel information on real-time population isolation and concerns stemming from the pandemic's social and economic impacts, via cellular mobility tracking and online search data, are potentially important interim surveillance resources. Using these measures, we employed transfer function model time-series analyses to estimate associations between daily mobility indicators (proportion of cellular devices completely at home and time spent at home) and Google Health Trends search volumes for terms pertaining to economic stress, mental health, and suicide during 2020 and 2021 both nationally and in New York City. During the first pandemic wave in early-spring 2020, over 50% of devices remained completely at home and searches for economic stressors exceeded 60,000 per 10 million. We found large concurrent associations across analyses between declining mobility and increasing searches for economic stressor terms (national proportion of devices at home: cross-correlation coefficient (CC) = 0.6 (p-value <0.001)). Nationally, we also found strong associations between declining mobility and increasing mental health and suicide-related searches (time at home: mood/anxiety CC = 0.53 (<0.001), social stressor CC = 0.51 (<0.001), suicide seeking CC = 0.37 (0.006)). Our findings suggest that pandemic-related isolation coincided with acute economic distress and may be a risk factor for poor mental health and suicidal behavior. These emergent relationships warrant ongoing attention and causal assessment given the potential for long-term psychological impact and suicide death. As US populations continue to face stress, Google search data can be used to identify possible warning signs from real-time changes in distributions of population thought patterns.

Central European journal of operations research (CJOR) "operations research applied to health services (ORAHS) in Europe: general trends and ORAHS 2020 conference in Vienna, Austria"

This articles provides a short summary of the research topics and latest research results of the European Working Group "Operations Research Applied to Health Services" (ORAHS) organized as an e-conference in Juli 2020 at the University of Vienna, Austria (https://orahs2020.univie.ac.at/). Furthermore, challenges for OR in health care including application areas, decision support systems, general trends, and modelling techniques are briefly illustrated from an European and international perspective by providing selected essential literature reviews.

The Influence of China's COVID-19 Treatment Policy on the Sustainability of Its Social Health Insurance System

Background

While past experiences show that a health system financing mechanism can support resilience to shocks, the impact on the sustainability of the financing system is exceptionally important considering the magnitude of the COVID-19 pandemic. The role of Social Health Insurance (SHI) in responding to the pandemic brings about an influence on insurance system sustainability. This study investigates the impact of China’s COVID-19 treatment policy on the sustainability of its SHI system, explores influences of the policy on Wuhan’s system, and discusses the effects of an assumed equivalent emergency on SHI funds for five other provincial capital cities in China.

Methods

The study was conducted using pay-as-you-go actuarial models of Urban Employee Basic Medical Insurance (UEBMI) and Urban and Rural Residents Basic Medical Insurance (URRBMI) funds, which constitute China’s basic health insurance system. Current and accumulated balances of the funds in 2020 are predicted and utilized to measure the sustainability of health insurance funds during emergencies.

Results

The findings suggest a disparity in the capacities of insurance schemes and localities. If the surplus before 2018 is not considered, it is likely that the URRBMI fund of Wuhan would suffer a deficit, whereas the UEBMI would retain a considerable surplus. To maintain the current actuarial balance of the URRBMI fund, coverage for ordinary inpatient and outpatient expenses would have to be significantly reduced in Wuhan, potentially affecting enrollees’ wellbeing. A similar situation may occur in three other cities, some with underdeveloped economies and lower per capita income are likely to be encountered with worse situation than Wuhan.

Conclusion

Concerning fragmentation of China’s SHI system, to strengthen longer-term preparedness to manage future emergencies, this study suggests the integration of insurance schemes and provincial pooling, fund balance adjusting and an emergency safety net are also advised. All options call for more public health investments.

Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession

Objective: To analyse the trends in chronic liver diseases and cirrhosis mortality, and the associated socioeconomic inequalities, in nine European cities and urban areas before and after the onset of the 2008 financial crisis. Methods: This is an ecological study of trends in three periods of time: two before (2000–2003 and 2004–2008), and one after (2009–2014) the onset of the economic crisis. The units of analysis were the geographical areas of nine cities or urban areas in Europe. We analysed chronic liver diseases and cirrhosis standardised mortality ratios, smoothing them with a hierarchical Bayesian model by each city, area, and sex. An ecological regression model was fitted to analyse the trends in socioeconomic inequalities, and included the socioeconomic deprivation index, the period, and their interaction. Results: In general, chronic liver diseases and cirrhosis mortality rates were higher in men than in women. These rates decreased in all cities during the financial crisis, except among men in Athens (rates increased from 8.50 per 100,000 inhabitants during the second period to 9.42 during the third). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality were found in six cities/metropolitan areas among men, and in four among women. Finally, in the periods studied, such inequalities did not significantly change. However, among men they increased in Turin and Barcelona and among women, several cities had lower inequalities in the third period. Conclusions: There are geographical socioeconomic inequalities in chronic liver diseases and cirrhosis mortality, mainly among men, that did not change during the 2008 financial crisis. These results should be monitored in the long term.

The 2008 Financial Crisis and Changes in Lifestyle-Related Behaviors in Italy, Greece, Spain, and Portugal: A Systematic Review

Italy, Greece, Spain, and Portugal have all been strongly affected by the 2008 financial crisis, which has had a negative impact on health. We systematically evaluated the effects of the crisis on lifestyle and socioeconomic inequalities. We conducted a literature search using MEDLINE, Embase, the Cochrane Library, and health economics databases for studies reporting quantitative comparisons before and after (or during) the crisis on the following risk behaviors: alcohol consumption, smoking habit, healthy diet, physical activity, and psychotropic drugs and substance abuse, without setting any age restrictions. We selected 34 original articles published between 2011 and 2020. During/after the crisis, alcohol consumption and substance abuse decreased, while psychotropic drug use increased. We also observed a deterioration in healthy eating behavior, with a reduction in fruit and vegetable consumption. Smoking habit and physical activity showed a more complex, controversial trend. Socioeconomic inequalities were affected by the recession, and the negative effects on unhealthy lifestyle tended to be more pronounced among the disadvantaged. These results suggest the need to implement health policies and interventions aimed at monitoring risk behaviors, with special regard to disadvantaged people, and considering the potential additional impact of the COVID-19 pandemic.

Social Determinants of Health Influencing the New Zealand COVID-19 Response and Recovery: A Scoping Review and Causal Loop Diagram

The Coronavirus pandemic of 2019–20 (COVID-19) affected multiple social determinants of health (SDH) across the globe, including in New Zealand, exacerbating health inequities. Understanding these system dynamics can support decision making for the pandemic response and recovery measures. This study combined a scoping review with a causal loop diagram to further understanding of the connections between SDH, pandemic measures, and both short- and long-term outcomes in New Zealand. The causal loop diagram showed the reinforcing nature of structural SDH, such as colonization and socio-economic influences, on health inequities. While balancing actions taken by government eliminated COVID-19, the diagram showed that existing structural SDH inequities could increase health inequities in the longer term, unless the opportunity is taken for socio-economic policies to be reset. Such policy resets would be difficult to implement, as they are at odds with the current socio-economic system. The causal loop diagram highlighted that SDH significantly influenced the dynamics of the COVID-19 impact and response, pointing to a need for purposeful systemic action to disrupt the reinforcing loops which increase health inequities over time. This will require strong systems leadership, and coordination between policy makers and implementation at local level.

Socioeconomic inequalities in suicide mortality in European urban areas before and during the economic recession

BACKGROUND

Few studies have assessed the impact of the financial crisis on inequalities in suicide mortality in European urban areas. The objective of the study was to analyse the trend in area socioeconomic inequalities in suicide mortality in nine European urban areas before and after the beginning of the financial crisis.

METHODS

This ecological study of trends was based on three periods, two before the economic crisis (2000-2003, 2004-2008) and one during the crisis (2009-2014). The units of analysis were the small areas of nine European cities or metropolitan areas, with a median population ranging from 271 (Turin) to 193 630 (Berlin). For each small area and sex, we analysed smoothed standardized mortality ratios of suicide mortality and their relationship with a socioeconomic deprivation index using a hierarchical Bayesian model.

RESULTS

Among men, the relative risk (RR) comparing suicide mortality of the 95th percentile value of socioeconomic deprivation (severe deprivation) to its 5th percentile value (low deprivation) were higher than 1 in Stockholm and Lisbon in the three periods. In Barcelona, the RR was 2.06 (95% credible interval: 1.24-3.21) in the first period, decreasing in the other periods. No significant changes were observed across the periods. Among women, a positive significant association was identified only in Stockholm (RR around 2 in the three periods). There were no significant changes across the periods except in London with a RR of 0.49 (95% CI: 0.35-0.68) in the third period.

CONCLUSIONS

Area socioeconomic inequalities in suicide mortality did not change significantly after the onset of the crisis in the areas studied.

Self-Rated Health Trajectory Changes According to Employment Transition: A Korean Prospective Cohort Study

OBJECTIVE

To investigate the impact of employment transitions on self-rated health (SRH) trajectories.

METHODS

We used data from the Korean Labor and Income Panel Study 2003 to 2016. Employment transitions were measured using four categories: continuously non-working, continuously working, labor force exit, and labor force entry. For examination of the time trends in the likelihood of poor SRH, we calculated the annual odds ratios with those from 2003 as the reference, using generalized estimating equations.

RESULTS

The time trends in the likelihood of poor SRH showed a significant increasing trend in the labor force exit group, while continuously working group and labor force entry group showed significantly decreasing patterns.

CONCLUSIONS

Labor force exit was associated with a substantial increase in prevalence of poor SRH, while labor force entry was associated with a decrease in prevalence of that.

[Prevalence of diabetes mellitus and its complications and characterization of healthcare gaps based on triangulation of studies]

Diabetes mellitus is one of the most prevalent diseases worldwide and is among the leading causes of loss of healthy years of life, which is aggravated in Brazil by accelerated population aging. This study aims to measure the problem of diabetes mellitus and its complications and characterize healthcare for diabetics in Brazil, according to regions. Prevalence rates were estimated using a multinomial regression model, and characterization of healthcare was based on triangulation between the Brazilian National Health Survey (PNS), the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), and data from the Popular Pharmacy program. Diabetes prevalence in Brazil was 9.2%, according to the multinomial model, and prevalence in the corrected PNS (self-report + altered glycated hemoglobin - HbA1c ≥ 6.5) was 9.4%. The proportion of diabetes mellitus underreporting in the country was 42.5%, reaching 72.8% in the North. Among individuals diagnosed with diabetes mellitus, half presented HbA1c ≥ 6.5. Insufficient fundus eye examination (only 40% on average), with major regional variation (North 25% - Southeast 52%), is reflected in the high prevalence of retinopathy. Insufficient examination of feet (only 30%), can lead to more amputations. About 80% of diabetics used medications, indicating a persistently high proportion still without treatment. Healthcare deficiencies for diabetics lead to greater morbidity, hospitalizations (15%), and visits to emergency departments (27%, PMAQ). The scenario in 2012, although not ideal, occurred in a context of strengthening of the Brazilian Unified National Health System (SUS). The growing prevalence of diabetes mellitus and cutbacks in public health budgeting call for serious reflection on control of the disease in the coming years.

Impact of the Economic Crisis on Endocarditis Mortality in Spain: A Nationwide Study

Economic recession has dire consequences on overall health. None have explored the impact of economic crisis (EC) on infective endocarditis (IE) mortality. We conducted a retrospective, nationwide, temporal trend study analyzing mortality trends by age, sex, and adverse outcomes in patients diagnosed with IE in Spain from 1997 to 2014. Data were divided into two subperiods: pre-EC (January 1997-August 2008) and post-EC (September 2008-December 2014). A total of 25 952 patients presented with IE. The incidence increased from 301.4 to 365.1 per 10 000 000 habitants, and the mortality rate rose from 24.3% to 28.4%. Those aged >75 years experienced more adverse outcomes. Complications due to sepsis, shock, acute kidney injury requiring dialysis, and heart failure increased after the EC onset, and expenditures soared to €16 216. Expenditure per community was related to mortality (P < .001). The EC resulted as an independent predictor for mortality (hazard ratio 1.06; 95% confidence interval 1.01-1.11). Incidence and mortality rate in patients with IE after the onset of the EC have increased as a result of rising adverse outcomes despite an overall increased investment.

ECONOMIC RECESSION AND THE RISK OF CANCER - A Cohort Study from Eastern Finland

BackgroundLittle is known about the role of economic recessions in the risk of cancer. Therefore, we evaluated the impact of the severe economic recession in Finland between 1991-1994 on the incidence of all cancers and cancer subtypes among middle-age and older population.MethodsFrom the Kuopio Ischemic Heart Disease Risk Factor Study (KIHD), a population-based sample of 1620 women and men aged 53-73 years were examined between 1998-2001. The cancer-free participants completed a questionnaire on the possible impact of the 1990s recession in Finland on their lives. Incident cases of cancer were obtained through record linkage with the Finnish Cancer Registry. Cox proportional hazards regression was used to estimate hazard ratios (HR) of incident cancer events after adjusting for possible confounders.ResultsA total of 1096 cancer-free participants had experienced socioeconomic hardships due to the recession at the baseline. During 20 years of follow-up, 473 participants developed cancer. After adjustment for age, baseline socioeconomic position and lifestyle factors, the risk of all cancers was 32% higher among men who experienced socioeconomic hardships compared to those who did not (HR 1.32, 95%CI, 0.99-1.75, p=0.05). Prostate-genital cancer was 71% higher among men with hardships (n=103, HR=1.71, 95%CI, 1.06-2.74, p=0.02). No association was observed between socioeconomic hardships and subsequent risk of total or any subtype of cancer among women.Conclusions:The 1990s economic recession was associated with increased risk of all cancers, especially prostate-genital cancer among Finnish middle-age and older men, but no association with cancer was observed in women.

Monitoring drug consumption in Innsbruck during coronavirus disease 2019 (COVID-19) lockdown by wastewater analysis

The coronavirus disease 2019 (COVID-19) has developed into a serious pandemic with millions of cases diagnosed worldwide. To fight COVID-19 pandemic, over 100 countries instituted either a full or partial lockdown, affecting billions of people. In Tyrol, first lockdown measures were taken on 10 March 2020. On 16 March 2020, a curfew went into force which ended on 1 May 2020. On 19 March 2020, Tyrol as a whole was placed in quarantine which ended on 7 April 2020. The governmental actions helped reducing the spread of COVID-19 at the cost of significant effects on social life and behaviour. Accordingly, to provide a comprehensive picture of the population health status not only input from medical and biological sciences is required, but also from other sciences able to provide lifestyle information such as drug use. Herein, wastewater-based epidemiology was used for studying temporal trends of licit and illicit drug consumption during lockdown and quarantine in the area of the Tyrolean capital Innsbruck (174,000 inhabitants). On 35 days between 12 March 2020 and 15 April 2020, loads of 23 markers were monitored in wastewater. Loads determined on 292 days between March 2016 and January 2020 served as reference. During lockdown, changes in the consumption patterns of recreational drugs (i.e. cocaine, amphetamine, 3,4-methylenedioxymethamphetamine, methamphetamine, and alcohol) and pharmaceuticals for short-term application (i.e. acetaminophen, codeine, and trimethoprim) were detected. For illicit drugs and alcohol, it is very likely that observed changes were linked to the shutdown of the hospitality industry and event cancelation which led to a reduced demand of these compounds particularly on weekends. For the pharmaceuticals, further work will be necessary to clarify if the observed declines are indicators of improved population health or of some kind of restraining effect that reduced the number of consultations of medical doctors and pharmacies.

Health-related factors of psychological distress during the COVID-19 pandemic among non-health workers in Spain

BACKGROUND

Non-health workers engaged in essential activities during the pandemic are less researched on the effects of COVID-19 than health workers.

OBJECTIVE

to study the differences between those who work away from home and those who do so from home, when the effects of fear of contagion cross with those of confinement, about the psychological distress during the COVID-19 in Spain.

DESIGN

Observational descriptive cross-sectional study.

DATA SOURCES

The study was carried out receiving 1089 questionnaires from non-health workers that were working away from home and doing so from their homes. The questionnaire included sociodemographic and occupational data, physical symptoms, self-perceived health, use of preventive measures and possible contacts, and the Goldberg GHQ-12.

RESULTS

71.6% of non-health female workers and 52.4% of non-health male workers had psychological distress, with differences among those working away from home and those working from home. The level of psychological distress among non-health workers is predicted by 66.5% through the variables: being a woman, 43 years old or younger, having a home with no outdoor spaces, poor perception of health, number of symptoms, and having been in contact with contaminated people or material. Among workers who work away from home, being self-employed is another predictive variable of distress.

CONCLUSION

More than the half of the sample showed inadequate management of the psychological distress. There are modifiable factors which provide necessary elements to support a positive attitude of the workers, such as: knowledge of hygiene, transmission of the virus, protective measures, and social distancing measures.

Using a Formal Strategy of Priority Setting to Mitigate Austerity Effects Through Gains in Value: The Role of Program Budgeting and Marginal Analysis (PBMA) in the Brazilian Public Healthcare System

The fiscal regime implemented in Brazil with the constitutional amendment 95 (EC-95) of December 2016 froze primary expenditures for 20 years, including healthcare spending. Previous studies have estimated strong negative effects of this policy on the health of Brazilians. Although there has been a constant pressure to repeal EC-95, this policy is unlikely to be changed in the near future. Thus, there is also a need to take actions within its own terms in order to mitigate its harmful consequences on population health. Shedding light on the existing evidence about the impact of austerity on health, the present work discusses how decision-makers can use a formal framework of decision making in priority setting and resource allocation to tackle the amplified budgetary strain. Drawing on principles of Program Budgeting and Marginal Analysis (PBMA), efficiency can be improved by shifting spending from low-value to higher-value areas, avoiding the "across-the-board cut" caused by non-differential consideration of expenditures in a context of mismatched growth of demand and supply of healthcare. By evaluating opportunity costs of investment and disinvestment proposals on the basis of multiple criteria and marginal analysis, the Brazilian public healthcare system could obtain gains in value, achieving better performance and attenuating the relative decline in spending on health brought by an austerity scenario.

An analysis of death trends in Argentina, 1990-2017, with emphasis on the effects of economic crises

Background

Economic crises have heterogeneous effects on population-level mortality between high- and low- or middle-income countries. Argentina - a middle income country- has suffered economic crises repeatedly over the past 30 years and is a model case study for the effects of economic crises on mortality.

Methods

Over 28 years (1990-2017), all death records in Argentina were analysed at the most disaggregated level possible (departments, that is, second-level administrative divisions). Age-and-sex-standardized all-cause mortality, premature death (<75 years) and the probability of death at different ages for both the entire population and each socio-economic quintile were calculated by level of unsatisfied basic needs (UBNs). Standardized rates are reported as biannual average and 95% confidence interval.

Results

Considered globally since the beginning of the series and using the 1990-1 biennium as a reference category, the standardized death rate was significantly reduced from biennium 2 (1992-3) to biennium 14 (2016-7), interrupted by two statistically significant increases in mortality, in years 2002-3 and 2016-7. In 2002-3, women had greater increase in mortality than men, and in 2016-7, even more so. The probability of dying before 75 years of age increased significantly in the last biennium, mostly among people between 50 and 74 years in the most deprived quintiles.

Conclusions

Despite significant overall improvement over time, economic crises impose severe increases in mortality, especially among vulnerable groups such as the poor, the elderly, and women.

An analysis of death trends in Argentina, 1990-2017, with emphasis on the effects of economic crises

BACKGROUND

Economic crises have heterogeneous effects on population-level mortality between high- and low- or middle-income countries. Argentina - a middle income country- has suffered economic crises repeatedly over the past 30 years and is a model case study for the effects of economic crises on mortality.

METHODS

Over 28 years (1990-2017), all death records in Argentina were analysed at the most disaggregated level possible (departments, that is, second-level administrative divisions). Age-and-sex-standardized all-cause mortality, premature death (<75 years) and the probability of death at different ages for both the entire population and each socio-economic quintile were calculated by level of unsatisfied basic needs (UBNs). Standardized rates are reported as biannual average and 95% confidence interval.

RESULTS

Considered globally since the beginning of the series and using the 1990-1 biennium as a reference category, the standardized death rate was significantly reduced from biennium 2 (1992-3) to biennium 14 (2016-7), interrupted by two statistically significant increases in mortality, in years 2002-3 and 2016-7. In 2002-3, women had greater increase in mortality than men, and in 2016-7, even more so. The probability of dying before 75 years of age increased significantly in the last biennium, mostly among people between 50 and 74 years in the most deprived quintiles.

CONCLUSIONS

Despite significant overall improvement over time, economic crises impose severe increases in mortality, especially among vulnerable groups such as the poor, the elderly, and women.

Reducing the prevalence of low-back pain by reducing the prevalence of psychological distress: Evidence from a natural experiment and implications for health care providers

OBJECTIVE

To determine whether exogenously reduced psychological distress reduces reported low-back pain (LBP) and is associated with reduced medical visits for LBP.

DATA SOURCES

National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, 1998-2004.

STUDY DESIGN

We estimate a fuzzy regression discontinuity model in which a discontinuity in the prevalence of psychological distress is identified by exogenous national events. We examine whether this discontinuity induced a corresponding discontinuity in the prevalence of LBP. We additionally estimate a regression discontinuity model to determine associated changes in medical visits with LBP as the primary complaint.

PRINCIPAL FINDINGS

The prevalence of LBP was discontinuously reduced by one-fifth due to the exogenous national discontinuous reduction in psychological distress. This discontinuity in LBP cannot be explained by discontinuities in employment, insurance, injuries/poisoning, general health status, or other factors. We find an associated three-fifth discontinuous reduction in medical visits with LBP as the primary complaint.

CONCLUSIONS

On a monthly basis, 2.1 million (P < .01) adults ceased to suffer LBP due to the national reduction in psychological distress, and associated medical visits with LBP as the primary complaint declined by 685 000 (P < .01).

Socio-economic inequalities on cancer mortality in nine European areas: The effect of the last economic recession

BACKGROUND

The effect of inequalities aggravated by economic recessions in the mortality rates of certain diseases has been previously described. In this study, we analyzed the relationship between socio-economic deprivation and cancer mortality. We focused on lung, colon, prostate, and breast cancers in nine European urban areas over three periods: two before (2000-2003 and 2004-2008) and one after (2009-2014) the onset of the 2008 financial crisis.

METHODS

This is an ecological study of trends. The units of analysis were small areas within nine European urban areas. We used a composite deprivation index as a socio-economic indicator. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyze the evolution of socio-economic inequalities, we fitted an ecological regression model that included the socio-economic indicator, the period of time, and the interaction between these terms.

RESULTS

In men, socio-economic inequalities in all-cancer and lung cancer mortality were observed in most of the cities studied, but did not increase after the onset of the economic crisis. In women, only two cities (Stockholm and London) showed socio-economic inequalities in all-cancer and lung cancer mortality; there was also no increase in inequalities.

CONCLUSIONS

Our results did not validate our hypothesis that inequalities increase in times of crisis. However, they emphasize the importance of socio-economic measurements for understanding mortality inequalities, and can be used to inform prevention strategies and help plan local health programs aimed at reducing health inequalities.

Lingering Impact of Starting Working Life During a Recession: Health Outcomes of Survivors of the "Employment Ice Age" (1993-2004) in Japan

Background

A growing amount of evidence demonstrates the adverse impacts of economic downturns on population health. However, the extent to which the macroeconomic conditions at labor market entry affect health outcomes in later life remains relatively understudied. This study focused on the health outcomes of the cohort who entered the labor market during the “employment ice age” (EIA; 1993–2004) in Japan, when young people had difficulty finding jobs after graduating from college or high school.

Methods

We used repeated cross-sectional data (N = 3,054,782; 1,500,618 men and 1,554,164 women) obtained from an 11-wave population-based nationwide survey conducted every 3 years from 1986 through 2016. We considered three health outcomes: being in hospital, subjective symptoms, and self-rated health (SRH). We employed two types of statistical analyses: an age-period-cohort (APC) analysis, which controlled for age and period (wave) effects, and a difference-in-differences (DiD) analysis, in which the EIA experience was regarded as a treatment.

Results

The APC analysis confirmed the relative disadvantage of the EIA cohort for all three outcomes; for instance, the odds ratio of poor SRH for the EIA cohort was 1.29 (95% confidence interval [CI], 1.21–1.38) for men and 1.25 (95% CI, 1.17–1.34) for women. The DiD analysis confirmed the robustness of these results, especially for men.

Conclusions

The results underscored the lingering impact of the macroeconomic conditions at labor market entry on health outcomes in later life in Japan.

Soziale Ungleichheit und COVID-19: Sozialepidemiologische Perspektiven auf die Pandemie

Die neue Coronavirus-Erkrankung (COVID-19) trifft bestimmte Bevölkerungsgruppen stärker als andere. Sozialepidemiologische Muster der Pandemie, die über Alters- und Geschlechterunterschiede hinausgehen, sind bislang jedoch kaum erforscht. Für Deutschland liegen bisher nur sehr wenige Befunde zu den sozialen Determinanten von COVID-19 vor. Erste Berichte aus anderen westlichen Industrieländern lassen erkennen, dass Menschen in sozioökonomisch deprivierten Regionen und People of Color ein erhöhtes Risiko haben, schwer an COVID-19 zu erkranken und daran zu versterben. Hierfür dürften soziale Ungleichheiten im Infektionsrisiko, die sich durch unterschiedliche Lebens- und Arbeitsbedingungen ergeben, wie auch soziale Ungleichheiten in der Suszeptibilität und den Risikofaktoren für schwere COVID-19-Krankheitsverläufe, insbesondere das Vorhandensein von Vorerkrankungen, eine wesentliche Rolle spielen. Diese sind auch für Deutschland umfassend dokumentiert. Somit kann angenommen werden, dass auch hierzulande Menschen mit einem niedrigen sozioökonomischen Status besonders stark betroffen sein könnten, was vermutlich erst im weiteren Verlauf der Pandemie mehr zutage treten wird. Auch die sozialen, ökonomischen und psychosozialen Folgen der Maßnahmen, die zur Eindämmung der Pandemie getroffen werden, könnten verschiedene sozioökonomische Gruppen ungleich stark treffen. Damit hat die COVID-19-Pandemie insgesamt das Potenzial, soziale und gesundheitliche Ungleichheiten zu verstärken. Es braucht sozialepidemiologische Untersuchungen des COVID-19-Geschehens, um Maßnahmen des Gesundheits- und Infektionsschutzes zielgruppengerecht, evidenzbasiert und unter Berücksichtigung gesundheitlicher Chancengerechtigkeit weiterentwickeln zu können.

Bringing in critical frameworks to investigate agenda-setting for the social determinants of health: Lessons from a multiple framework analysis

Public health scholars have increasingly called for greater attention to the political and policy processes that enable or constrain successful prioritisation of health on government agendas. Much research investigating policy agenda-setting in public health has focused on the use of single frameworks, in particular Kingdon's Multiple Streams Framework. More recently, scholars have argued that blending complementary policy frameworks can enable greater attention to a wider range of drivers that influence government agendas away from or towards progressive social and health policies. In this paper, we draw on multiple policy process frameworks in a study of agenda-setting for Australia's first national paid parental leave scheme. Introduced in 2011 after decades of advocacy, this scheme provides federal government-funded parental leave for eighteen weeks' pay at the minimum wage for primary caregivers, with evaluations showing improved health and equity outcomes. Drawing on empirical data collected from documentary sources and interviews with 25 key policy informants, we find that a combination of policy frameworks; in this case, Kingdon's Multiple Streams; Advocacy Coalition Framework; Punctuated Equilibrium; Narrative Policy Framework; and Policy Feedback helped explain how this landmark social policy came about. However, none of these frameworks were adequate without situating them within a critical feminist lens which enabled an explicit focus on the gendered nature of power. We argue that, alongside making use of policy process frameworks, social determinants of health policy research needs to engage with critical frameworks which share an explicit agenda for improving people's daily living conditions and the re-distribution of power, money, and resources in ways that promote health equity.

Epidemiological Trends of Fungemia in Greece with a Focus on Candidemia during the Recent Financial Crisis: a 10-Year Survey in a Tertiary Care Academic Hospital and Review of Literature

Updated information on the epidemiology of candidemia, particularly during severe socioeconomic events, is important for proper management of these infections. A systematic literature review on candidemia in Greece and a retrospective surveillance study were conducted in a tertiary university hospital during the years of the recent financial crisis (2009 to 2018) in order to assess changes in incidence rates, patient characteristics, species distribution, antifungal susceptibilities, and drug consumption. The average annual incidence of 429 candidemic episodes was 2.03/10,000 bed days, with 9.88 in adult intensive care units (ICUs), 1.74 in surgical wards, and 1.81 in internal medicine wards, where a significant increase was observed (1.15, 1.85, and 2.23/10,000 bed days in 2009 to 2011, 2012 to 2014, and 2015 to 2018, respectively; P = 0.004). Candida albicans was the most common species (41%), followed by Candida parapsilosis species complex [SC] (37%), Candida glabrata SC (11%), Candida tropicalis (7%), Candida krusei (1%), and other rare Candida spp. (3%). Mixed infections were found in 20/429 (4.7%) cases, while 33 (7%) cases were due to non-Candida spp. Overall, 44/311 (14%) isolates were resistant/non-wild type (WT) to the nine antifungals tested, with 23/113 (20%) C. parapsilosis SC and 2/34 (6%) C. glabrata SC isolates being resistant to fluconazole (1 panechinocandin and 2 panazole resistant). All isolates were susceptible/WT to amphotericin B and flucytosine. While the overall consumption of antifungals diminished (P = 0.02), with a mean of 17.93 defined daily doses (DDD)/100 bed days, increased micafungin use was correlated with the rise in C. parapsilosis SC (P = 0.04). A significant increase of candidemia in internal medicine wards and of C. parapsilosis SC infections was found during the years of financial crisis. Although resistance rates remain low (<14%), fluconazole-resistant C. parapsilosis SC and multidrug-resistant C. glabrata SC isolates are of major concern.

Effect of the Financial Crisis on Socioeconomic Inequalities in Mortality in Small Areas in Seven Spanish Cities

Background: The aim of this study was to analyze the trend in socioeconomic inequalities in mortality in small areas due to several specific causes before (2001–2004, 2005–2008) and during (2009–2012) the economic crisis in seven Spanish cities. Methods: This ecological study of trends, with census tracts as the areas of analysis, was based on three periods. Several causes of death were studied. A socioeconomic deprivation index was calculated for each census tract. For each small area, we estimated standardized mortality ratios, and controlled for their variability using Bayesian models (sSMR). We also estimated the relative risk of mortality according to deprivation in the different cities, periods, and sexes. Results: In general, a similar geographical pattern was found for the socioeconomic deprivation index and sSMR. For men, there was an association in all cities between the deprivation index and all-cause mortality that remained stable over the three periods. For women, there was an association in Barcelona, Granada, and Sevilla between the deprivation index and all-cause mortality in the third period. Patterns by causes of death were more heterogeneous. Conclusions: After the start of the financial crisis, socioeconomic inequalities in total mortality in small areas of Spanish cities remained stable in most cities, although several causes of death showed a different pattern.

Risk of child poverty and social exclusion in two Spanish regions: social and family determinants

OBJECTIVE

Describe the risk of poverty and social exclusion in children aged 8-11 years from Gipuzkoa and Valencia (Spain), through AROPE (At Risk Of Poverty or Social Exclusion) indicators, and evaluate their associated factors in the INMA Project (Childhood and Environment).

METHOD

Families in Gipuzkoa and Valencia (394 and 382, respectively) completed a questionnaire in 2015-2016. Low work intensity (LWI), at risk of poverty (RP) and material deprivation (MD) were estimated. AROPE consisted in meeting any of the previous sub-indicators. Socio-demographic, family and parental characteristics were considered. Frequencies, Venn's diagrams, and chi-square and Fisher tests were used in bivariate analysis and logistic regression in multivariate analysis.

RESULTS

For LWI, RP, MD and AROPE, prevalence of 2.5%, 5.6%, 2.3% and 7.2% were obtained in Gipuzkoa, and 8.1%, 31.5%, 7.8% and 34.7% in Valencia, respectively. In the multivariate analysis, the AROPE was associated in both areas with maternal social class and non-nuclear families. In Gipuzkoa, it was also related to maternal education. In Valencia, other factors were the mother's foreign origin, and paternal education and smoking.

CONCLUSION

There is higher AROPE prevalence in Valencia. Social class and family type were shared factors, but a differential pattern is observed in other social determinants. It is essential to implement social policies to reduce this axis of inequalities in health, especially in childhood.

[Financial fraud and health: a qualitative approach]

During the economic crisis, developed countries have experienced financial fraud, with effects on the physical and mental health of the people affected, and on social domains. Based on the theoretical framework in literature reviews and in quantitative studies, this paper aims to obtain evidence on the effects of financial fraud on health and on the family and social environments of those affected. An intentional sample of 32 people affected by abusive and multi-currency mortgages, preferred and swap stock in Madrid was approached. In-depth interviews were conducted, and the resulting data was analysed using content analysis. Fraud-affected individuals had conditions of age, sex, educational level and occupations that possibly allowed them to accumulate economic resources throughout the course of their lives and, predictably in many cases, to take out fraudulent financial products, based on trust in the financial institutions. Financial fraud has led to the emergence of various processes of anomia and adverse health effects. The consequences on health were physical ailments (symptoms and diseases in various systems and parts of the body) and mental disorders (anxiety, depression, suicidal ideation), all affecting lifestyles, behaviour and personal and social relationships, both in affected individuals and their families. The increase in the use of medical drugs and health services serves as a final corollary to the imbalances on the affected people's health. Individuals and the Spanish society demand public health policy measures to mitigate the effects on health and the recovery of their confidence in the banking and political system.

Austrian firearm legislation and its effects on suicide and homicide mortality: A natural quasi-experiment amidst the global economic crisis

Background:

Restriction of access to suicide methods has been shown to effectively reduce suicide mortality rates.

Aims:

To examine how the global economic crisis of 2008 and the firearm legislation reform of 1997 affected suicide and homicide mortality rate within Austria.

Methods:

Official data for the years 1985–2016 for firearm certificates, suicide, homicide, unemployment rates and alcohol consumption were examined using auto regressive error and Poisson regression models.

Results:

Firearm certificates, total suicide mortality rate, suicide and homicides by firearms, and the fraction of firearm suicides/homicides among all suicides/homicides decreased after the firearm legislation reform in 1997. However, significant trend changes can be observed after 2008. The availability of firearm certificates significantly increased and was accompanied by significant changes in trends of firearm suicide and homicide rates. Concurrently, the total suicide mortality rate in 2008, for the first time since 1985, stopped its decreasing trend. While the total homicide rate further decreased, the fraction of firearm homicides among all homicides significantly increased.

Conclusion:

The initially preventative effect of the firearm legislation reform in Austria in 1997 seems to have been counteracted by the global economic downturn of 2008. Increased firearm availability was associated with corresponding increases in both firearm suicide and firearm homicide mortality. Restrictive firearm legislation should be an imperative part of a country’s suicide prevention programme. Although firearm legislation reform may have long-lasting effects, societal changes may facilitate compensatory firearm acquisitions and thus counteract preventive efforts, calling in turn again for adapted counter-measures.

[Social inequality and mental health]

Social inequality refers to the inequitable distribution of social prosperity including the resource of health. The relationship between social inequality and mental health can be established by means of indicators of social inequality throughout all age groups in Germany. There are social gradients of mental health on the population level, i.e. the linear relationship between social classes or status and state of health. Fundamental determinants of health disparity are cultural, social, political, and geographical conditions, which interact with the genetic make-up and epigenetic processes. These determinants also influence the management of developmental tasks during the life course and are of utmost importance for the development of mental disorders. The maladaptation to chronic stress is at the core of health disparity. Interventions at the individual behavioral level should comprise the development of stress management and coping strategies.

Going beyond health efficiency: What really matters?

Both citizens and policymakers demand the best possible results from a country's healthcare system. It is of utmost importance to accurately and objectively assess the efficiency of a healthcare system and to note the key indicators, where resources are lost, and possibilities for improvement. This paper evaluates the efficiency of health systems in 38 countries, mainly members of the Organization for Economic Co-operation and Development, using data envelopment analysis (DEA). In the first stage, bootstrapped Ivanovic distance is used to generate weights for the indicators, thus taking into consideration different country's goals, but not to the extent of reducing the possibility of comparison. The analysis shows that human resources are the most important health system resource and countries should pay special attention to developing and employing competent medical workers. The reorganization of human resources and the funds allocated to them could also increase efficiency. The second stage examines environmental indicators to find the causes of inefficiency. No proof is found that any one basic health system funding model produces better health outcomes than the others. Obesity is identified as a major issue.

What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

Background

The 2014–2016 Ebola outbreak was a wake-up call regarding the critical importance of resilient health systems. Fragile health systems can become overwhelmed during public health crises, further exacerbating the human, economic, and political toll. Important work has been done to describe the general attributes of a health system resilient to these crises, and the next step will be to identify the specific capacities that health systems need to develop and maintain to achieve resiliency.

Methods

We conducted a scoping review of the literature to identify recurring themes and capacities needed for health system resiliency to infectious disease outbreaks and natural hazards and any existing implementation frameworks that highlight these capacities. We also sought to identify the overlap of the identified themes and capacities with those highlighted in the World Health Organization’s Joint External Evaluation. Sources of evidence included PubMed, Web of Science, OAIster, and the websites of relevant major public health organizations.

Results

We identified 16 themes of health system resilience, including: the need to develop plans for altered standards of care during emergencies, the need to develop plans for post-event recovery, and a commitment to quality improvement. Most of the literature described the general attributes of a resilient health system; no implementation frameworks were identified that could translate these elements into specific capacities that health system actors can employ to improve resilience to outbreaks and natural hazards in a variety of settings.

Conclusions

An implementation-oriented health system resilience framework could help translate the important components of a health system identified in this review into specific capacities that actors in the health system could work to develop to improve resilience to public health crises. However, there remains a need to further refine the concept of resilience so that health systems can simultaneously achieve sustainable transformations in healthcare practice and health service delivery as well as improve their preparedness for emergencies.

The importance of financial recession for mental health among students: short- and long-term analyses from an ecosocial perspective

Background and aim: Referring to the ecosocial theory and utilising the ‘natural experiment’ setting provided by the global recession at the beginning of 1990s, the aim of our study was to analyse the short- and long-term associations between trade and mental health in young students followed until mid-adulthood.

Method: The study was based on two prospective cohort studies, the older and the younger Northern Swedish Cohort which both consisted of all pupils in a middle-sized industrial town in Northern Sweden. At age 21, the younger cohort entered the labour market during the deep recession of the early 1990s, while the older cohort entered the labour market during the boom of the 1980s. Both cohorts were followed up with a high response rate in mid adulthood. For this study, all students were selected at age 21.

Results: At age 21, those who studied during recession had more depressive and functional somatic symptoms than those who studied during boom. The cohort differences did not remain over age: by the follow-up in early middle age the differences between the cohorts were non-significant, most notably due to decreased depressive symptoms in the younger cohort and increase of functional somatic symptoms in the older cohort.

Conclusions: The short-term mental health consequences of the business cycle seem to be more extensive than limited only to those who are unemployed, even though the possible long-term consequences seem to be more complex. Thus, the macrolevel had a great short-term impact on the individual level in relation to the microlevel setting of university/school. The chronosystem was also of major importance. Future research would benefit from taking the context into account.