Health Gain Research Articles

Education Level and Self-rated Health in the United States: Immigrants' Diminished Returns.

Although education is among the major socioeconomic status (SES) resources that influence populations' and individuals' health, social marginalization may reduce the health gain that follows access to SES indicators such as education, a pattern called marginalization-related diminished return (MDR). The literature on MDRs, however, has been mainly derived from studies that have defined marginalization based on race, ethnicity, and sexual orientation. Thus, more research is needed on MDRs that may follow as a result of immigration. To extend what is known on immigration status related MDRs, this study compared a national sample of immigrants and non-immigrants for the effect of education on the poor self-rated health (SRH) of adults in the United States. With a cross-sectional design, this study employed data from the 2015 National Health Interview Survey (NHIS), a survey that had enrolled 33,654 adults who were either immigrants (n = 6225; 18.5%) or non-immigrants (n = 27 429; 81.5%). The independent variable was education level, treated as a categorical variable. The dependent variable was SRH treated as a dichotomous variable. Race, ethnicity, age, gender, marital status, and region were the confounders. Immigration (nativity) was the moderator. Logistic regression was used for data analysis. Higher education credentials were associated with better SRH in the pooled sample; however, immigration showed a significant statistical interaction with education level (college graduation) on the outcome. This interaction was indicative of a smaller protective effect of college graduation on poor SRH among immigrants than non-immigrant adults. In line with the MDRs framework, the effect of education on SRH is weaker for immigrants than for non-immigrant adults. There is a need to help highly educated immigrants to mobilize their human capital to secure their best health outcomes, similar to non-immigrants. Such strategies may require bold and innovative policy solutions to reduce discrimination against immigrants, so they can more effectively translate their education and human capital into tangible outcomes such as health.

Cataract surgery for falls prevention and improving vision: modelling the health gain, health system costs and cost-effectiveness in a high-income country

AimTo estimate the health gain, health system costs and cost-effectiveness of cataract surgery when expedited as a falls prevention strategy (reducing the waiting time for surgery by 12 months) and...

The cost-effectiveness of conducting three versus two reverse transcription-polymerase chain reaction tests for diagnosing and discharging people with COVID-19: evidence from the epidemic in Wuhan, China

ObjectivesThe objectives were to evaluate the effectiveness of conducting three versus two reverse transcription-PCR (RT-PCR) tests for diagnosing and discharging people with COVID-19 with regard to public health and clinical...

Development and Validation of a Clinical Prediction Tool for Seasonal Influenza Vaccination in England

Timely identification of patients likely to miss seasonal influenza vaccination (SIV) could help health care practitioners tailor services and gain efficiency. To develop and validate a predictive model of SIV uptake among at-risk adults. This prognostic study constructed a prediction model for vaccine uptake by adults at increased risk of influenza-associated complications. Drawing from the Clinical Practice Research Datalink database's records of primary care data of 324 284 adults routinely collected at general practices across England from January 2011 to December 2016, logistic regression models were trained on data from patients registered from January 2012 to December 2013 and validated with out-of-sample data from patients registered from January 2015 to December 2016. Data were extracted from the database December 2018 and analyzed between September 2019 and December 2019. Covariates included sex, age, race/ethnicity, smoking status, socioeconomic status, previous pneumococcal vaccination, prior season SIV uptake, and clinical risk conditions. The main outcome was patient-level SIV uptake. Model performance was measured via misclassification rate, Brier score, sensitivity, specificity, and area under the curve. The training data sets consisted of 324 284 (aged 18 to 64 years) and 186 426 (aged 65 years or older) patients. The mean (SD) age in the training data among patients aged 18 to 64 years was 45 (13) years; 161 487 (49.8%) were women, and 102 133 (31.5%) were categorized as white. Among patients aged 65 years or older, the mean (SD) age was 77 (8) years; 96 169 (51.6%) were women, and 64 996 (34.9%) were categorized as white. The validation data sets consisted of 35 210 patients aged 18 to 64 years and 25 497 aged 65 years or older. The mean (SD) age in the validation data set among patients aged 18 to 64 years was 42 (14) years; 17 296 (49.1%) were women, and 13 346 (37.9%) were categorized as white. Among patients aged 65 years or older, the mean (SD) age was 73 (8) years; 13 135 (51.5%) were women, and 9641 (37.8) were categorized as white. Among patients aged 18 to 64 years, SIV uptake was 35.9% (95% CI, 35.7%-36.0%) and 32.6% (95% CI, 32.1%-33.1%) for the training and validation data sets, respectively. Among patients aged 65 years or older, SIV uptake was 83.1% (95% CI, 82.9%-83.2%) and 76.1% (95% CI, 75.5%-76.6%) for the training and validation data sets, respectively. Prior season SIV uptake and pneumococcal vaccination status were the best predictors of SIV uptake. Predicted SIV uptake probabilities for patients aged 18 to 64 years were reliable, but biased toward underpredicting, whereas, among patients aged 65 years or older, they were variable and biased toward overpredicting. Briefly, in out-of-sample validation among patients aged 18 to 64 years, misclassification rates were 0.163 to 0.164, Brier scores were 0.124 to 0.125, area under the receiver operating characteristic curve values ranged from 0.876 to 0.877, sensitivity ranged from 0.705 to 0.720, and specificity ranged from 0.896 to 0.902. In patients aged 65 years or older, misclassification rates were 0.120 to 0.125, Brier scores were 0.0953 to 0.0959, area under the receiver operating characteristic curve was 0.877, sensitivity ranged from 0.919 to 0.936, and specificity ranged from 0.680 to 0.753. This study suggests that data obtained from primary care records could accurately predict SIV uptake among at-risk adults. Further research is needed to assess the feasibility and efficacy of implementing this model in clinical settings.

Impact of tax and tobacco-free generation on health-adjusted life years in the Solomon Islands: a multistate life table simulation

ObjectiveTo estimate health-adjusted life years (HALY) gained in the Solomon Islands for the 2016 population over the remainder of their lives, for three interventions: hypothetical eradication of cigarettes; 25% annual...

Cost-effectiveness analysis of an outreach model of Hepatitis C Virus (HCV) assessment to facilitate HCV treatment in primary care.

The effects of hepatitis C virus (HCV), such as morbidity and mortality associated with cirrhosis and liver cancer, is a major public health issue in Australia. Highly effective treatment has recently been made available to all Australians living with HCV. A decision-analytic model was developed to evaluate the cost-effectiveness of the hepatology partnership, compared to usual care. A Markov model was chosen, as it is state-based and able to include recursive events, which accurately reflects the natural history of the chronic and repetitive nature of HCV. Cost-effectiveness of the new model of care is indicated by the incremental cost-effectiveness ratio (ICER), where the mean change to costs associated with the new model of care is divided by the mean change in quality adjusted life-years (QALYs). Ten thousand iterations of the model were run, with the majority (73%) of ICERs representing cost-savings. In comparison to usual care, the intervention improves health outcomes (22.38 QALYs gained) and reduces costs by $42,122 per patient. When compared to usual care, a partnership approach to management of HCV is cost-effective and good value for money, even when key model parameters are changed in scenario analyses. Reduction in costs is driven by improved efficiency of the new model of care, where more patients are treated in a timely manner, away from the expensive tertiary setting. From an economic perspective, a reduction in hospital-based care is a positive outcome and represents a good investment for decision-makers who wish to maximise health gain per dollar spent.

Health Gain, Cost Impacts, and Cost-Effectiveness of a Mass Media Campaign to Promote Smartphone Apps for Physical Activity: Modeling Study.

BackgroundPhysical activity smartphone apps are a promising strategy to increase population physical activity, but it is unclear whether government mass media campaigns to promote these apps would be a cost-effective use of public funds.ObjectiveWe aimed to estimate the health impacts, costs, and cost-effectiveness of a one-off national mass media campaign to promote the use of physical activity apps.MethodsWe used an established multistate life table model to estimate the lifetime health gains (in quality-adjusted life years [QALYs]) that would accrue if New Zealand adults were exposed to a one-off national mass media campaign to promote physical activity app use, with a 1-year impact on physical activity, compared to business-as-usual. A health-system perspective was used to assess cost-effectiveness. and a 3% discount rate was applied to future health gains and health system costs.ResultsThe modeled intervention resulted in 28 QALYs (95% uncertainty interval [UI] 8-72) gained at a cost of NZ $81,000/QALY (2018 US $59,500; 95% UI 17,000-345,000), over the remaining life course of the 2011 New Zealand population. The intervention had a low probability (20%) of being cost-effective at a cost-effectiveness threshold of NZ $45,000 (US $32,900) per QALY. The health impact and cost-effectiveness of the intervention were highly sensitive to assumptions around the maintenance of physical activity behaviors beyond the duration of the intervention.ConclusionsA mass media campaign to promote smartphone apps for physical activity is unlikely to generate much health gain or be cost-effective at the population level. Other investments to promote physical activity, particularly those that result in sustained behavior change, are likely to have greater health impacts.

Prostate Cancer Screening in Middle-Aged and Older American Men: Combined Effects of Ethnicity and Years of Schooling

Prostate cancer screening is more commonly utilized by highly educated people. As shown by marginalization-related diminished returns (MDRs), the effects of socioeconomic status (SES) such as education on the health outcomes are considerably smaller for ethnic minorities than for Whites. The role of MDRs as a source of ethnic health disparities is, however, still unknown. The current study had two aims: first, to explore the association between years of schooling and having taken a prostate-specific antigen (PSA) test among men in the US, and second, to explore ethnic differences in this association. This study was a secondary analysis of data from the National Health Interview Survey (NHIS-2015). The data of 5,053 men aged 55 years or older who were either Latino, non-Latino, African-American, or White were analyzed. Years of schooling was the independent variable. The dependent variable was taking a PSA test sometime during one's lifetime. Age, region, and employment were the control variables. Ethnicity was the focal moderating variable. Binary logistic regression was used for data analysis. A higher number of years of schooling was associated with higher odds of having taken a PSA test, net of all confounders. Ethnicity showed a significant statistical interaction with years of schooling on having taken a PSA test. This interaction was suggestive of a smaller slope for Latino men than non-Latino men. White and African American men did not show differential effects of years of schooling on having taken a PSA test. Similar to the MDRs patterns in other domains, non-Latino White men show more health gain from their years of schooling than Latino men. Highly educated Latino men still need programs to encourage their use of prostate cancer screening.

Sodium bicarbonate to improve physical function in patients over 60 years with advanced chronic kidney disease: the BiCARB RCT.

Advanced chronic kidney disease is common in older people and is frequently accompanied by metabolic acidosis. Oral sodium bicarbonate is used to treat this acidosis, but evidence is lacking on whether or not this provides a net gain in health or quality of life for older people. The objectives were to determine whether or not oral bicarbonate therapy improves physical function, quality of life, markers of renal function, bone turnover and vascular health compared with placebo in older people with chronic kidney disease and mild acidosis; to assess the safety of oral bicarbonate; and to establish whether or not oral bicarbonate therapy is cost-effective in this setting. A parallel-group, double-blind, placebo-controlled randomised trial. The setting was nephrology and geriatric medicine outpatient departments in 27 UK hospitals. Participants were adults aged ≥ 60 years with advanced chronic kidney disease (glomerular filtration rate category 4 or 5, not on dialysis) with a serum bicarbonate concentration of < 22 mmol/l. Eligible participants were randomised 1 : 1 to oral sodium bicarbonate or matching placebo. Dosing started at 500 mg three times daily, increasing to 1 g three times daily if the serum bicarbonate concentration was < 22 mmol/l at 3 months. The primary outcome was the between-group difference in the Short Physical Performance Battery score at 12 months, adjusted for baseline. Other outcome measures included generic and disease-specific health-related quality of life, anthropometry, 6-minute walk speed, grip strength, renal function, markers of bone turnover, blood pressure and brain natriuretic peptide. All adverse events were recorded, including commencement of renal replacement therapy. For the health economic analysis, the incremental cost per quality-adjusted life-year was the main outcome. In total, 300 participants were randomised, 152 to bicarbonate and 148 to placebo. The mean age of participants was 74 years and 86 (29%) were female. Adherence to study medication was 73% in both groups. A total of 220 (73%) participants were assessed at the 12-month visit. No significant treatment effect was evident for the primary outcome of the between-group difference in the Short Physical Performance Battery score at 12 months (-0.4 points, 95% confidence interval -0.9 to 0.1 points; p = 0.15). No significant treatment benefit was seen for any of the secondary outcomes. Adverse events were more frequent in the bicarbonate arm (457 vs. 400). Time to commencement of renal replacement therapy was similar in both groups (hazard ratio 1.22, 95% confidence interval 0.74 to 2.02; p = 0.43). Health economic analysis showed higher costs and lower quality of life in the bicarbonate arm at 1 year, with additional costs of £564 (95% confidence interval £88 to £1154) and a quality-adjusted life-year difference of -0.05 (95% confidence interval -0.08 to -0.01); placebo dominated bicarbonate under all sensitivity analyses for incremental cost-effectiveness. The trial population was predominantly white and male, limiting generalisability. The increment in serum bicarbonate concentrations achieved was small and a benefit from larger doses of bicarbonate cannot be excluded. Oral sodium bicarbonate did not improve a range of health measures in people aged ≥ 60 years with chronic kidney disease category 4 or 5 and mild acidosis, and is unlikely to be cost-effective for use in the NHS in this patient group. Once other current trials of bicarbonate therapy in chronic kidney disease are complete, an individual participant meta-analysis would be helpful to determine which subgroups, if any, are more likely to benefit and which treatment regimens are more beneficial. Current Controlled Trials ISRCTN09486651 and EudraCT 2011-005271-16. The systematic review is registered as PROSPERO CRD42018112908. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 27. See the NIHR Journals Library website for further project information.

Economic Strain Deteriorates While Education Fails to Protect Black Older Adults Against Depressive Symptoms, Pain, Self-rated Health, Chronic Disease, and Sick Days.

A large body of empirical evidence on Minorities' Diminished Returns (MDRs) suggests that educational attainment shows smaller health effects for Blacks compared to Whites. At the same time, economic strain may operate as a risk factor for a wide range of undesired mental and physical health outcomes in Black communities. The current study investigated the combined effects of education and economic strain on the following five health outcomes in Black older adults in underserved areas of South Los Angeles: depressive symptoms, number of chronic diseases, pain intensity, self-rated health, and sick days. This cross-sectional study included 619 Black older adults residing in South Los Angeles. Data on demographic factors (age and gender), socioeconomic characteristics, economic strain, health insurance, living arrangement, marital status, health behaviors, depressive symptoms, pain intensity, number of chronic diseases, sick days, and self-rated health were collected. Five linear regressions were used to analyze the data. Although high education was associated with less economic strain, it was the economic strain, not educational attainment, which was universally associated with depressive symptoms, pain intensity, self-rated health, chronic diseases, and sick days, independent of covariates. Similar patterns emerged for all health outcomes suggesting that the risk associated with economic strain and lack of health gain due to educational attainment are both robust and independent of type of health outcome. In economically constrained urban environments, economic strain is a more salient social determinant of health of Black older adults than educational attainment. While education loses some of its protective effects, economic strain deteriorates health of Black population across domains. There is a need for bold economic and social policies that increase access of Black communities to cash at times of emergency. There is also a need to improve the education quality in the Black communities.

Modeling Personalized Adjuvant TreaTment in EaRly stage coloN cancer (PATTERN)

AimTo develop a decision model for the population-level evaluation of strategies to improve the selection of stage II colon cancer (CC) patients who benefit from adjuvant chemotherapy.MethodsA Markov cohort model with a one-month cycle length and a lifelong time horizon was developed. Five health states were included; diagnosis, 90-day mortality, death other causes, recurrence and CC death. Data from the Netherlands Cancer Registry were used to parameterize the model. Transition probabilities were estimated using parametric survival models including relevant clinical and pathological covariates. Subsequently, biomarker status was implemented using external data. Treatment effect was incorporated using pooled trial data. Model development, data sources used, parameter estimation, and internal and external validation are described in detail. To illustrate the use of the model, three example strategies were evaluated in which allocation of treatment was based on (A) 100% adherence to the Dutch guidelines, (B) observed adherence to guideline recommendations and (C) a biomarker-driven strategy.ResultsOverall, the model showed good internal and external validity. Age, tumor growth, tumor sidedness, evaluated lymph nodes, and biomarker status were included as covariates. For the example strategies, the model predicted 83, 87 and 77 CC deaths after 5 years in a cohort of 1000 patients for strategies A, B and C, respectively.ConclusionThis model can be used to evaluate strategies for the allocation of adjuvant chemotherapy in stage II CC patients. In future studies, the model will be used to estimate population-level long-term health gain and cost-effectiveness of biomarker-based selection strategies.

Distributional impact of the Malawian Essential Health Package.

In low- and middle-income countries (LMICs), making the best use of scarce resources is essential to achieving universal health coverage. The design of health benefits packages creates the opportunity to select interventions on the basis of explicit objectives. Distributional cost-effectiveness analysis (DCEA) provides a framework to evaluate interventions based on two objectives: increasing population health and reducing health inequality. We conduct aggregate DCEA of potential health benefits package interventions to demonstrate the feasibility of this approach in LMICs, using the case of the Malawian health benefits package. We use publicly available survey and census data common to LMICs and describe what challenges we encountered and how we addressed them. We estimate that diseases targeted by the health benefits package are most prevalent in the poorest population quintile and least prevalent in the richest quintile. The survey data we use indicate socioeconomic patterns in intervention uptake that diminish the population health gain and inequality reduction from the package. We find that a similar set of interventions would be prioritized when impact on health inequality is incorporated alongside impact on overall population health. However, conclusions about the impact of individual interventions on health inequalities are sensitive to assumptions regarding the health opportunity cost, the utilization of interventions, the distribution of diseases across population groups and the level of aversion to inequality. Our results suggest that efforts to improve access to the Essential Health Package could be targeted to specific interventions to improve the health of the poorest fastest but that identifying these interventions is uncertain. This exploratory work has shown the potential for applying the DCEA framework to inform health benefits package design within the LMIC setting and to provide insight into the equity impact of a health benefits package.

PMU99 A NEW APPROACH TO MEASURE EFFECTIVE COVERAGE FOR ASSESSING HEALTH SYSTEMS PERFORMANCE

Effective coverage (EC) is a measure of health service performance. The use of EC, however, is limited by the frequent lack of information about one of its constitutive parameters: the quality of health services, understood as the fraction between observed and an optimum health gain from health interventions. We proposed a novel method that overcomes this issue. The procedure calculated the fraction of avoidable disability (or health-state utilities) in people receiving treatment, over the disability attributable to a disease. This was done using a regression model that predicts disability at individual level, where exposure to the disease without treatment, and with treatment (G2) were key variables. We compared total predicted disability in three scenarios: actual, worst (‘0’ coverage), and plausible (assuming quantile 90 of predicted health gain distribution was the optimum performance in G2). We demonstrated this procedure using data from 4359 individuals aged 50+ at Wave 2 (2004-2005) of the English Longitudinal Study of Ageing (ELSA). Hypertension was used as an example disease. People reporting treatment were considered covered. Disability was measured as an index score, ranging from 0-100. The prevalence of hypertension was 25.3% [23.9-26.5] and accounted for 1.9% [1.9-1,9] of total disability in the population. The coverage of treatment was 80.5% [78.2-82.9]. In people with hypertension, given current coverage, 48.8% [47.5-50.1] of the predicted disability in the worst scenario would have been avoided (i.e. relative-EC), and 2.0% [2.0-2.1] in the whole population (i.e. absolute-EC). The average health gain in people with treatment was 54.0% [52.9-55.0] (i.e. health benefit), while the avoidable disability against the optimum health gain was 68.6% [67.1-70.2] (i.e. quality). Effective coverage given the optimum health gain was 54.9% [53.6-56.1]. We developed a pragmatic way to estimate EC, which overcame the issue of the lack of information about health service quality.

PCN65 THE CHALLENGE OF VALUE-BASED PRICING IN COMBINATION THERAPY:THE CASE OF TRASTUZUMAB AND PERTUZUMAB IN HER2+ METASTATIC BREAST CANCER

Under current reimbursement (CR) practice, although an add-on medicine in a combination therapy may produce marginal value in terms of health gain, the original therapy may also share in the reward for this additional value. We examine a “marginal value-based reimbursement” (MVBR) model in which an add-on therapy can fully obtain its marginal value. Our aim was to evaluate the impact of MVBR model on effective price (EP) and value-based price (VBP) of an add-on therapy, as compared to CR model. We used the addition of pertuzumab to trastuzumab and docetaxel (PHT) for human epidermal growth factor receptor 2 positive metastatic breast cancer as a case study.

Area-level deprivation, childhood dental ambulatory sensitive hospitalizations and community water fluoridation: evidence from New Zealand.

We examined the association between area-level deprivation and dental ambulatory sensitive hospitalizations (ASH) and considered the moderating effect of community water fluoridation (CWF). The hypothesis was that higher levels of deprivation are associated with higher dental ASH rates and that CWF will moderate this association such that children living in the most deprived areas have greater health gain from CWF. Dental ASH conditions (dental caries and diseases of pulp/periapical tissues), age, gender and home address identifier (meshblock) were extracted from pooled cross-sectional data (Q3, 2011 to Q2, 2017) on children aged 0-4 and 5-12 years from the National Minimum Dataset, New Zealand (NZ) Ministry of Health. CWF was obtained for 2011 and 2016 from the NZ Institute of Environmental Science and Research. Dental ASH rates for children aged 0-4 and 5-12 years (/1000) were calculated for census area units (CAUs). Multilevel negative binomial models investigated associations between area-level deprivation, dental ASH rate and moderation by CWF status. Relative to CWF (2011 and 2016), no CWF (2011 and 2016) was associated with increased dental ASH rates in children aged 0-4 [incidence rate ratio (IRR) = 1.171 (95% confidence interval 1.064, 1.288)] and aged 5-12 years [IRR = 1.181 (1.084, 1.286)]. An interaction between area-level deprivation and CWF showed that the association between CWF and dental ASH rates was greatest within the most deprived quintile of children aged 0-4 years [IRR = 1.316 (1.052, 1.645)]. CWF was associated with a reduced dental ASH rate for children aged 0-4 and 5-12 years. Children living in the most deprived areas showed the greatest effect of CWF on dental ASH rates, indicating that the greater health gain from CWF occurred for those with the highest socio-economic disadvantage. Variation in CWF contributes to structural inequities in oral-health outcomes for children.

Addressing Health Care Disparities: A Radical Perspective and Proposal.

This paper begins by rethinking the sociological theory that social conditions are fundamental causes of health disparities and that controlling disease ironically increases or creates them. While usually true, the radical proposal of non-profit health care and pharmaceutical development could ameliorate health disparities if a nation like Canada or a region like the EU looked to radically different but successful models such as the Drugs for Neglected Diseases initiative. It uses what could be called entrepreneurial collaboration for public health markets and inverts intellectual property to public health IP to maximize health gain instead of profits.

Orphan Drugs Offer Larger Health Gains but Less Favorable Cost-effectiveness than Non-orphan Drugs.

Orphan drugs offer important therapeutic options to patients suffering from rare conditions, but are typically considerably more expensive than non-orphan drugs, leading to questions about their cost-effectiveness. To compare the value of orphan and non-orphan drugs approved by the FDA from 1999 through 2015. We searched the PubMed database to identify estimates of incremental health gains (measured in quality-adjusted life-years, or QALYs) and incremental costs that were associated with orphan and non-orphan drugs compared with preexisting care. We excluded pharmaceutical industry-funded studies from the dataset. When a drug was approved for multiple indications, we considered each drug-indication pair separately. We then compared incremental QALY gains, incremental costs, and incremental cost-effectiveness ratios for orphan and non-orphan drugs using the Mann-Whitney U (MWU) test (to compare median values of the different distributions) and the Kolmogorov-Smirnov (KS) test (to compare the shape of different distributions). We identified estimates for 49 orphan drug-indication pairs, and for 169 non-orphan drug-indication pairs. We found that orphan drug-indication pairs offered larger median incremental health gains than non-orphan drug-indication pairs (0.25 vs. 0.05 QALYs; MWU p = 0.0093, KS p = 0.02), but were associated with substantially higher costs ($47,652 vs. $2870; MWU p < 0.001, KS p < 0.001) and less favorable cost-effectiveness ($276,288 vs. $100,360 per QALY gained; MWU p = 0.0068, KS p = 0.009). Our study suggests that orphan drugs often offer larger health gains than non-orphan drugs, but due to their substantially higher costs they tend to be less cost-effective than non-orphan drugs. Our findings highlight the challenge faced by health care payers to provide patients appropriate access to orphan drugs while achieving value from drug spending.

Modelling the health impact of food taxes and subsidies with price elasticities: The case for additional scaling of food consumption using the total food expenditure elasticity

Food taxes and subsidies are one intervention to address poor diets. Price elasticity (PE) matrices are commonly used to model the change in food purchasing. Usually a PE matrix is generated in one setting then applied to another setting with differing starting consumptions and prices of foods. This violates econometric assumptions resulting in likely mis-estimation of total food consumption. In this paper we demonstrate this problem, canvass possible options for rescaling all consumption after applying a PE matrix, and illustrate the use of a total food expenditure elasticity (TFEe; the expenditure elasticity for all food combined given the policy-induced change in the total price of food). We use case studies of: NZ$2 per 100g saturated fat (SAFA) tax, NZ$0.4 per 100g sugar tax, and a 20% fruit and vegetable (F&V) subsidy. We estimated changes in food purchasing using a NZ PE matrix applied conventionally, and then with TFEe adjustment. Impacts were quantified for pre- to post-policy changes in total food expenditure and health adjusted life years (HALYs) for the total NZ population alive in 2011 over the rest of their lifetime using a multistate lifetable model. Two NZ studies gave TFEe's of 0.68 and 0.83, with international estimates ranging from 0.46 to 0.90 (except a UK outlier of 0.04). Without TFEe adjustment, total food expenditure decreased with the tax policies and increased with the F&V subsidy-implausible directions of shift given economic theory and the external TFEe estimates. After TFEe adjustment, HALY gains reduced by a third to a half for the two taxes and reversed from an apparent health loss to a health gain for the F&V subsidy. With TFEe adjustment, HALY gains (in 1000's) were: 1,805 (95% uncertainty interval 1,337 to 2,340) for the SAFA tax; 1,671 (1,220 to 2,269) for the sugar tax; and 953 (453 to 1,308) for the F&V subsidy. If PE matrices are applied in settings beyond where they were derived, additional scaling is likely required. We suggest that the TFEe is a useful scalar, but we also encourage other researchers to examine this issue and propose alternative options.

Scraping the Web for Public Health Gains: Ethical Considerations from a 'Big Data' Research Project on HIV and Incarceration.

Web scraping involves using computer programs for automated extraction and organization of data from the Web for the purpose of further data analysis and use. It is frequently used by commercial companies, but also has become a valuable tool in epidemiological research and public health planning. In this paper, we explore ethical issues in a project that "scrapes" public websites of U.S. county jails as part of an effort to develop a comprehensive database (including individual-level jail incarcerations, court records and confidential HIV records) to enhance HIV surveillance and improve continuity of care for incarcerated populations. We argue that the well-known framework of Emanuel et al. (2000) provides only partial ethical guidance for the activities we describe, which lie at a complex intersection of public health research and public health practice. We suggest some ethical considerations from the ethics of public health practice to help fill gaps in this relatively unexplored area.

PENGARUH ELEMEN EKUITAS MEREK TERHADAP KEPUTUSAN PEMBELIAN PISANG “SUNPRIDE” DI KOTA BANDAR LAMPUNG

This research aims to analyze the effect of brand equity elements on the purchasing decision of "Sunpride" bananas in Bandar Lampung City. The basic method of this research is descriptive. The method of determining the location is purposive in Bandar Lampung City. The sampling using nonprobability sampling techniques, namely purposive sampling. The sample was 100 respondents. The analysis uses multiple linear regression analysis. The results indicate the elements of brand equity (brand awareness, brand associations, perceived quality, and brand loyalty) simultaneously have a positive effect on the purchasing decision of "Sunpride". Brand awareness, brand association and brand loyalty individually have a positive effect on the purchasing decision while the variable perceived quality has no effect. Known brands that have a relationship with health benefits and gain customer satisfaction will establish confidence in consumers to make purchasing decision of "Sunpride" bananas. Brand loyalty is the most influential variable on the purchasing decision of "Sunpride" bananas in Bandar Lampung City.