Population-level Health Research Articles

Utilizing Drones to Assess the Body Condition of Tamanend’s Bottlenose Dolphins (Tursiops erebennus) in the Charleston Estuarine System

Body condition is a measure of an animal’s energy reserves relative to its body structure that provides important information about individual- and population-level health. Monitoring the body condition of free-ranging cetaceans has historically been difficult, but in recent years, the unmanned aerial system (UAS, or “drone”) has facilitated noninvasive ways of estimating the cetacean body condition. The Charleston Estuarine System (CES) includes the estuarine and coastal ecosystems surrounding Charleston, South Carolina, and is utilized by Tamanend’s bottlenose dolphins (Tursiops erebennus) throughout the year. The main goals of this study were (1) to test if UASs are suitable for monitoring body condition of dolphins in an estuarine environment, and (2) to determine if site, season, and age class influence the body condition of dolphins in the CES. Land-based UAS surveys were conducted at four sites throughout the CES between September 2022 and May 2023. The body condition of each dolphin was evaluated using images of the individual positioned flat with a straight body at the surface, and a linear mixed effects model was constructed to determine which effects were associated with significant differences in dolphin body condition. After filtering images for quality, 428 images of 174 unique dolphins were included in the final analysis, with repeated body condition estimates of 24 dolphins from multiple seasons. Both season and age class were significant predictors of dolphin body condition, but site was not. In addition, individual dolphins were catalogued in a Drone Dolphin ID database, which allowed some dolphins’ unique body condition changes to be tracked over time. These findings provide an important baseline for dolphin body condition in the CES that can be built upon in future studies to better understand how body condition changes in response to environmental and anthropogenic stressors or for different age classes.

Population-level health impact of hypothetical waning 1-dose human papillomavirus vaccination and 2-dose mitigation strategies in a high cervical cancer burden setting

Abstract Background We simulated the impact of hypothetical waning scenarios of a 1-dose human papillomavirus (HPV) vaccination paired with switching to 2-dose mitigation strategies guided by empirical vaccine trial reporting timelines. Methods Using 2 independent mathematical models fitted to a high-burden setting, we projected the cumulative cervical cancer cases averted over 85 years for alternative HPV vaccination scenarios under 2 program adoption timelines: 1) de novo introduction of a 1-dose HPV vaccination and 2) a switch from an existing 2-dose HPV vaccination program to a 1-dose vaccination. We assumed 80% vaccination coverage with the bivalent vaccine and an average duration of a 1-dose HPV vaccine protection of either 30 or 25 years with 100% efficacy. We varied the eligible age group(s) at program introduction and the 2-dose mitigation (single-age cohort or multi-age cohort). If needed for mitigation, reintroduction of 2-dose vaccination was assumed to occur in 2036 (ie, 30 years after initiation of the Costa Rica Vaccine Trial). Results Under both vaccine adoption timelines, the models projected that countries could achieve the same level of health benefits by switching to 2 doses in 2036 using a multi-age cohort approach as with initiating a 2-dose or 1-dose vaccination program with no waning. With only a single-age cohort 2-dose mitigation approach, 98%-99% of cases would be prevented compared with the health benefits of 2 doses or a noninferior, durable 1 dose. Conclusions Countries hesitant to adopt a 1-dose HPV vaccination program may have opportunities to leverage the benefits and efficiency of a 1-dose schedule while awaiting longer-term reporting from 1-dose durability studies, including Costa Rica Vaccine Trial.

Translational science and related disciplines.

Translational research moves scientific discoveries and innovations across the development spectrum for a particular target or disease, trying to bridge in a multidisciplinary fashion the gap between laboratory scientific discoveries and practical, real-world applications in medicine and in healthcare. Translational research aims to move research findings across settings, specific languages, methodologies, and study designs, from laboratory to clinical practice and ultimately into community- and population-level health benefits. In contrast, translational science is a distinct field, which evolved over time toward a systematic study and practice of operationalizing the translation of content from one language, ecosystem, environment, contextual landscape, culture, discipline, area, or domain into another. It involves systematic and transdisciplinary integration of knowledge from basic science, clinical research and population science to improve human health, better longevity, and to ensure disease- and disability-free lives. Translational science often uses knowledge, operational frameworks, and specific capabilities borrowed from other specialties, disciplines, and fields such as operations management, implementation and dissemination science, quality improvement and management, project management, public health, intervention science, change management and leadership, decision science, design thinking, functional design, data science, communication and marketing science, etc. The main goal of this article is to open a series of thematic reviews in this journal, introducing the reader to the main definitions, contingencies, touchpoints, and overlapping areas between translational science and these related specialties, disciplines, and fields of study. Transdisciplinary capabilities borrowing from these related specialties can create a robust translational science machinery for health systems, research organizations, and innovation hubs.

Estimating risk using the novel Particulate Matters years index (ePM-years index). A report from the nationwide EP-PARTICLES study

Abstract Background Air pollution is the largest environmental risk factor, especially for cardiovascular disease (CVD). In this study, we present an original concept of estimating the risk associated with exposure to air pollution: the Particulate Matters years index (ePM-years index). Objective To assess the predictive performance of the ePM-years index. Methods The ePM-years index is an indicator of hypothetical exposure to air pollution. It is estimated by multiplying the number of years spent in a given environment by the difference between the average annual PM2.5 concentration and the allowed level of pollution given by World Health Organization (WHO) guidelines (Figure 1). We collected data from 2011 to 2020 on mortality and hospitalizations from National Health Fund and the Central Statistical Office in Poland, respectively. For further analysis, we used an age-standardized rate (SR), established on the European Standard Population structure. The source of air pollution data was GEM-AQ air quality modeling system. All data were connected with TERYT codes, all analyses were conducted at the county level (LAU-1) and then aggregated to the voivodeship level (NUTS-2). Poisson regression models were used to estimate associations between CVD mortality, ePM-years, and population level social and health status. We also estimated the attributable fraction of CVD mortality due to air pollution using AirQ+ methodology from the WHO. Results We recorded 4,010,531 deaths including 1,669,464 (41.6%) deaths due to CVD with a median age of 78.16 (SD=12.54), and 53.4% of females (N=914,932). Current smokers amounted to 29.9% (23.4%-33.2%). The main causes of death were coronary artery disease [405,268 (24.3%)] and heart failure [376,592 (22.6%)]. The mean Gross Domestic Product (GDP) per capita was 9644 EUR (7517-12,048), and the mean yearly PM2.5 concentration was 23.3 (SD=6.3) μg/m3, corresponding with the mean ePM-index 35.8 (21.5-66.6) in analysed time. The SR for CVD mortality was 500.3 (min. 461.9 – max. 604.5), the SR hospitalization rates were as follows: hypertension 312 (299-342), diabetes 90 (78.9-95.9), and HF 557.9 (310-728.4). There was an association of the ePM-years index with CVD mortality (shown as increase per 10 ePM-years): In Model 1 adjusted for GDP, risk ratio (RR) 1.023 (95% confidence interval (CI): 1.002-1.044); in Model 2 adjusted for comorbidities, RR=1.025 (95%CI: 1.004-1.046); in Model 3 adjusted for GDP, comorbidities and weather conditions RR=1.027 (95%CI: 1.005-1.049). We estimated that 16.2% (N=324,460) [95%CI: 12.54% -17.9%] of CVD deaths were attributable to PM2.5 exposure, using the WHO's air quality guideline as the reference. Conclusions The ePM-years index may be used as a tool for risk stratification for patients and incorporated into CVD outcomes prediction models. The index can help with planning of appropriate primary and secondary prevention schemes related to long-term pollution exposure.

Culturally-relevant physical activity for public health promotion: global evidence synthesis

Abstract Background The WHO has noted the importance of cultural insights for health. Culturally-relevant physical activity has a growing evidence base in many regions and specific populations, but the scope and scale for global health promotion is underexplored. Methods A multinational expert team used a critical literature review method to: (1) define culturally-relevant physical activity; (2) delineate relevant characteristics supporting inclusion in population-level health promotion and surveillance; and (3) provide agenda setting in research, policy, and practice from a global public health promotion perspective. The critical review method, which evaluates rather than summarizes literature, was chosen as the research evidence is complex, broad, and has not been synthesized previously from this perspective. Results Culturally-relevant physical activity was defined as practices that include physical activity based on a population’s cultural customs. These can be Indigenous (e.g., hula, an Indigenous dance of Native Hawaiians) or regional (e.g., Shota (Shotë), an Albanian folk dance). Practices have shared characteristics that support multi-dimensional value for health, engagement, and healing. These include a collectivist, intergenerational component, passed from elders and shared forward with children as part of a community. Many have foundations in nature, a strength for health and wellbeing in green and blue spaces. Many include traditional art, clothing, accessories, and music with deep significance, including care for the tools and location of practice (e.g, drums, boats, land). Many practices would not be captured in harmonized public health surveillance systems despite their value. From this synthesis, research hypotheses were created and next steps proposed. Conclusions This evidence synthesis supports engagement, planning, uptake, policy, surveillance, and study of culturally-relevant physical activity for public health promotion locally and globally. Key messages • An important strength of culturally-relevant physical activity is that it is context and population specific. However, this may hide the scope and scale of the existing evidence supporting this work. • This evidence synthesis confirms how culturally-relevant physical activity is valuable globally across shared assets in research and practice, supporting next steps for public health promotion.

Long COVID prevalence differences across 27 European countries that participated in the 2021 Survey of Health, Ageing and Retirement in Europe

Abstract The COVID-19 pandemic caused a significant burden in Europe, with over 60% of infected individuals developing Long COVID symptoms. Variations in Long COVID prevalence across countries are linked to individual-level factors, but the influence of population-based country-level characteristics remains unclear. Thus, our objective was to assess how country-level characteristics related to: (i) the way European countries responded to the COVID-19 pandemic, (ii) their population-level health status, (iii) provision and access to healthcare services, (iv) human development, governance, and environmental risk factors, are associated with Long COVID. We used a sample of 4,004 middle-aged and older adults from 27 European countries who, in summer 2021, participated in Corona Survey 2 (from Survey of Health, Ageing and Retirement in Europe) and who reported COVID-19 infection one year prior to the survey. To assess the potential role of country-level characteristics, while controlling for key individual-level factors, we estimated three sequential multilevel random intercept logistic regression models. Approximately 70% of respondents who had COVID-19 also experienced Long COVID symptoms and there were significant cross-country differences in Long COVID rates, ranging from 32% to 89%. About 13% of the total variance in the risk of having Long COVID can be attributed to cross-country differences and the remaining 87% to individual-level factors. The individual-level characteristics also accounted for 6% of the observed cross-country differences in Long COVID rates (compositional effects) while the country-level characteristics further reduced this variance by over 50%. Both individual and country-level factors influence Long COVID occurrence, emphasizing the need for tailored recovery plans, healthcare planning and resource allocation at the national level to address this condition.

Ceftazidime with avibactam for treating severe aerobic Gram-negative bacterial infections: technology evaluation to inform a novel subscription-style payment model.

To limit the use of antimicrobials without disincentivising the development of novel antimicrobials, there is interest in establishing innovative models that fund antimicrobials based on an evaluation of their value as opposed to the volumes used. The aim of this project was to evaluate the population-level health benefit of ceftazidime-avibactam in the NHS in England, for the treatment of severe aerobic Gram-negative bacterial infections when used within its licensed indications. The results were used to inform National Institute for Health and Care Excellence guidance in support of commercial discussions regarding contract value between the manufacturer and NHS England. The health benefit of ceftazidime-avibactam was first derived for a series of high-value clinical scenarios. These represented uses that were expected to have a significant impact on patients' mortality risks and health-related quality of life. Patient-level costs and health-related quality of life of ceftazidime-avibactam under various usage scenarios compared with alternative management strategies in the high-value clinical scenarios were quantified using decision modelling. Results were reported as incremental net health effects expressed in quality-adjusted life-years, which were scaled to 20-year population in quality-adjusted life-years using infection number forecasts based on data from Public Health England. The outcomes estimated for the high-value clinical scenarios were extrapolated to other expected uses for ceftazidime-avibactam. The clinical effectiveness of ceftazidime-avibactam relative to its comparators was estimated by synthesising evidence on susceptibility of the pathogens of interest to the antimicrobials in a network meta-analysis. In the base case, ceftazidime-avibactam was associated with a statistically significantly higher susceptibility relative to colistin (odds ratio 7.24, 95% credible interval 2.58 to 20.94). The remainder of the treatments were associated with lower susceptibility than colistin (odds ratio < 1). The results were sensitive to the definition of resistance and the studies included in the analysis. In the base case, patient-level benefit of ceftazidime-avibactam was between 0.08 and 0.16 quality-adjusted life-years, depending on the site of infection and the usage scenario. There was a high degree of uncertainty surrounding the benefits of ceftazidime-avibactam across all subgroups, and the results were sensitive to assumptions in the meta-analysis used to estimate susceptibility. There was substantial uncertainty in the number of infections that are suitable for treatment with ceftazidime-avibactam, so population-level results are presented for a range of scenarios for the current infection numbers, the expected increases in infections over time, and rates of emergence of resistance. The population-level benefit varied substantially across the scenarios, from 531 to 2342 quality-adjusted life-years over 20 years. This work has provided quantitative estimates of the value of ceftazidime-avibactam within its areas of expected usage within the NHS. Given existing evidence, the estimates of the value of ceftazidime-avibactam are highly uncertain. Future evaluations of antimicrobials would benefit from improvements to NHS data linkages, research to support appropriate synthesis of susceptibility studies, and application of routine data and decision modelling to assess enablement value. No registration of this study was undertaken. This award was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (NIHR award ref: NIHR135592), conducted through the Policy Research Unit in Economic Methods of Evaluation in Health and Social Care Interventions, PR-PRU-1217-20401, and is published in full in Health Technology Assessment; Vol. 28, No. 73. See the NIHR Funding and Awards website for further award information.

Epidemiological comparison of emergency department presentations with seasonal influenza or COVID-19 and an outcome of intensive care admission or death: A population-based records linkage study in New South Wales, Australia

COVID-19 and seasonal influenza are endemic causes of morbidity and mortality. This study aimed to compare the epidemiology of severe illness and risk of death among patients following emergency department (ED) presentation with either infection. De-identified, population-based, emergency department records in New South Wales, Australia, were probabilistically linked to population-level health outcome databases for the period 1 January 2015 to 28 February 2023. Included were patients allocated an ED diagnosis consistent with an acute respiratory infection. Logistic regression was used to examine the association of infecting virus with risk of a severe outcome (intensive care unit admission or death). Influenza infection was notified in 2335 and COVID-19 in 5053 patients with a severe outcome. The age distribution was similar for both viruses, except in <15-year-olds, where severe influenza was nearly three times more frequent. Overall, the odds of death among patients with COVID-19 was 1.65 (95% CI 1.43, 1.89) times higher than among those with influenza. This declined to 1.49 (95% CI 1.08, 2.06) times during the COVID-19 Omicron variant period. The Omicron variant arrived when background population COVID-19 vaccination coverage was >90%. Despite that, death was more frequent for COVID-19 than influenza.

Clinical and Sociodemographic Characteristics of New Residents of Assisted Living: A Nested Case-Control Study

ObjectiveTo examine transitions to an assisted living facility among community-dwelling older adults who received publicly funded home care services. DesignNested case-control study. Setting and ParticipantsLinked, population-level health system administrative data were obtained from adults aged 65 years and older who received home care services in Ontario, Canada, from April 1, 2018, to December 31, 2019. New residents of assisted living were matched on age, sex, and initiation date of home care (± 7 days) to community-dwelling home care recipients in a 1:4 ratio. MethodsClinical and functional status, health service use, sociodemographic variables, and community-level characteristics were examined; conditional logistic regression was used to model associations with a transition to an assisted living facility. ResultsThere were 2427 new residents of assisted living who were matched to 9708 home care recipients [mean (SD) age 85.5 (6.02) years, 72% female]. Most of the new residents were concentrated in urban communities and communities with higher income quintiles. New residents had an increased rate of physician-diagnosed dementia [adjusted hazard ratio (aHR), 1.28; 95% CI, 1.14–1.43], mood disorders (aHR, 1.17; 95% CI, 1.05–1.29), and cardiac arrhythmias (aHR, 1.19; 95% CI, 1.07–1.32). They also had higher rates of mild cognitive impairment (aHR, 1.43; 95% CI, 1.24–1.66), 2 or more falls (aHR, 1.29; 95% CI, 1.11–1.51), participation in activities of long-standing interest in the past 7 days (aHR, 1.29; 95% CI, 1.11–1.50), and a lower rate of a spouse or partner unpaid caregiver vs a child (aHR, 0.66; 95% CI, 0.56–0.79). Conclusions and ImplicationsNew residents of assisted living were mostly women, were cognitively impaired, had clinical comorbidities that could increase their risk of injuries, and had caregivers who were their children. These findings stress the importance of upscaling memory and dementia care in assisted living to address the needs of this population.

The application of deterministic and probabilistic methods of data linkage methods to link population and health data in western Uganda

IntroductionThere is increasing interest in record linkage between population-level data and health facility records to support epidemiological research in Africa. However, there is a lack of unique and ubiquitous identification systems for linkage. We applied two common data linkage approaches between population-level data from a health and demographic surveillance system and hospital records in Western Uganda. MethodologyWe established a data linkage system using deterministic and probabilistic linkage on population level data collected from 23 villages with hospital records. Deterministic linkage entails connecting a pair of records from the clinic and census data using a common identifier. Probabilistic linkage classifies a pair of records from two data sources as belonging to the same individual based on the statistical probability that a common set of identifiers drawn from the two data sources belong to the same individual. The preliminary results are on the deterministic approaches. ResultsUsing deterministic linkage, we fully linked 1061 records from 12/23 villages. Further updates of linkage with characteristics of the linked patients will be summarized in the next two months. Probabilistic linkage data will be presented with the characteristics of participants after the completion of the study, and the agreement between the two methods will be compared. Note to the results: Presentations during the conference will be done using finalized data. ConclusionPreliminary findings show that the linkage of population and health data is feasible. Findings could be used by researchers to design data linkage studies and answer different types of health and population research questions using innovative data science methods.

Enhancing population-level research among people who inject drugs: a validation and retrospective cohort study using health administrative data in Ontario, Canada

ObjectiveHealth administrative data can support population-level research among people who inject drugs (PWID), however these data sources remain underutilized due to the difficulty in identifying drug use in routinely collected data. We validated case-ascertainment algorithms to identify PWID and tested their application in a hepatitis C (HCV) cohort in Ontario, Canada. ApproachWe conducted a validation study using reference standard cohorts of PWID recruited via community-based studies and population controls linked to health administrative data in Ontario, Canada (1992-2020). Tested case-ascertainment algorithms included combinations of hospitalizations/emergency department (ED) visits for drug use/poisoning, physician visits for drug use, opioid agonist treatment (OAT), or injecting-related infections. Sensitivity and specificity were estimated for lifetime history and recent injecting (past 1-5 years). We applied a high-performing algorithm among all Ontarians with laboratory-confirmed HCV between 1999-2018, to identify a sub-cohort of PWID with HCV. ResultsAn algorithm including ≥1 hospitalization/ED visit or ≥1 physician visit for drug use or ≥1 OAT record had high accuracy for identifying IDU history (91.6% sensitivity, 94.2% specificity) and recent IDU (using 3 years lookback: 80.4% sensitivity, 99% specificity). When applied to a provincial cohort of 112,947 Ontarians diagnosed with HCV, this algorithm estimated 46% (N=52,248) had a history of IDU, of whom 52% (N=27,246) had an indication of recent IDU (within the past 3 years). ConclusionThe methods developed in this study can enhance the capacity of population-level health research among people who inject drugs and support applied public health interventions towards hepatitis C elimination.

Expanding opportunities in health data: Enhancing research by facilitating linkage of Ontario’s population-level health administrative data with data from patient support programs (PSPs)

ObjectivesPatient Support Programs (PSPs) provide real-world evidence on short-term outcomes and drug adherence for specialty care. These data are collected directly from patients by pharmaceutical companies. Data linkage is facilitated by a publicly-funded health research institute which houses population-based, individual-level health administrative data for 14 million Ontario residents in Canada since 1992. Linkage provides a more comprehensive and transparent view of patients’ pathways and care. ApproachIndustry-funded research conducted through the data &amp; analytic service must align with the institute’s mission, vision and values, and demonstrate a clear public benefit. For transparency, and to support broader public benefit and research access, final deliverables and analytic plans are posted on the institute’s website. Privacy impact assessments are conducted to ensure ethics approvals, consent and data sharing agreements are established, prior to data importation. To safeguard privacy, designated data covenantors encrypt and link the PSP data with in-house data holdings. Analyses are performed by senior analytic staff, providing researchers with summary-level reports. ResultsSince 2016, the institute has worked with organizations to link data for research, including PSP data on thousands of patients, enabling crucial insight into treatment patterns, drug adherence, costs and long-term outcomes. ConclusionLinkage of privately-owned PSP data with administrative health data at the institute, provides opportunities to identify gaps in care and improve quality of research. Data challenges around bias, transparency, completeness, and comprehensiveness are minimized. ImplicationsResults provide decision-makers and healthcare professionals with a trusted and comprehensive understanding of patient care pathways to improve health outcomes.

The ICES Indigenous Health Data Training Program: Building knowledge and strengthening capacity within Indigenous communities and organizations

Objective and ApproachThe responsible use of population-level health data requires equitable access, and considerations of Indigenous data sovereignty. There is often a baseline level of knowledge and understanding required to access data. To facilitate data access and strengthen capacity within Indigenous communities and organizations, we created the ICES Indigenous Health Data Training Program (IHDTP). ResultsThe IHDTP provides learning opportunities for Indigenous communities and organizational members to gain a better understanding of ICES data with a focus on Indigenous health. It provides an opportunity to gain practical knowledge on the research process, including how to develop a research question, understanding and interpreting research outputs, and knowledge translation. The program offers ongoing one-on-one technical support to participants, as well as the opportunity to submit a research project request for participating communities and organizations. ConclusionsThe IHDPT has been run several times, including both virtually and in-person, with a range of Indigenous partners. The materials presented in each administration of the program were tailored to the partner. Recorded sessions have also been created to allow a greater number of additional Indigenous partners to take the course flexibly. Program participants have indicated that the information learned would be used to advance issues that are important to their communities via policy, advocacy, and planning. ImplicationsThe IHDTP has enabled a variety of Indigenous partners to strengthen their understanding of health data and research to ultimately facilitate equitable and inclusive public health data access.

Mental health of the Pacific Island Nation communities: What the rest in the world can contribute to and learn from?

Creating Futures initiative has established a network of mental health professionals, researchers, and community members from the Pacific Island Nations (PIN), Australia, and New Zealand to address the growing challenges of mental health conditions compounded by the climate change crisis. The enormous amount of work done in Global Mental Health can be particularly helpful to improve population-level mental health. However, translation of this evidence base into practice poses several challenges. This perspective paper discusses the role of local culture and health systems context in determining the feasibility and acceptability of implementing and scaling up evidence-based interventions designed in an American-European context. The paper also advocates development (and evaluation) of mental health interventions in the PIN communities particularly and Global South generally and exporting these interventions to the rest of the world. COVID-19 crisis underlined the role of global cooperation as well as national level 'self-reliance'. In this post COVID-19 world, it will be desirable for the mental health community to cooperate and collaborate to scale up evidence-based interventions through rigorous contextualization and at the same time main-stream mental health interventions developed in the Global South by incorporating them in the Global Mental Health discourse.

Smoke-free legislation impact on the hospitality sector in the Republic of Georgia

IntroductionComprehensive smoke-free (SF) policies reduce secondhand smoke exposure and improve population-level health outcomes. However, some decision-makers heed the tobacco industry’s argument that SF policies negatively impact the hospitality sector. This...

Evaluating the impact of the 2010 Swedish choice reform in primary health care on avoidable hospitalization and socioeconomic inequities: an interrupted time series analysis using register data

BackgroundThe Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform’s impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities.MethodsThis register-based study used a multiple-group interrupted time-series design for the study period 2001–2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18–85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII).ResultsAll three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)).ConclusionsThe study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.

Study of Postacute Sequelae of COVID-19 Using Digital Wearables: Protocol for a Prospective Longitudinal Observational Study.

Postacute sequelae of COVID-19 (PASC) remain understudied in nonhospitalized patients. Digital wearables allow for a continuous collection of physiological parameters such as respiratory rate and oxygen saturation that have been predictive of disease trajectories in hospitalized patients. This protocol outlines the design and procedures of a prospective, longitudinal, observational study of PASC that aims to identify wearables-collected physiological parameters that are associated with PASC in patients with a positive diagnosis. This is a single-arm, prospective, observational study of a cohort of 550 patients, aged 18 to 65 years, male or female, who own a smartphone or a tablet that meets predetermined Bluetooth version and operating system requirements, speak English, and provide documentation of a positive COVID-19 test issued by a health care professional within 5 days before enrollment. The primary end point is long COVID-19, defined as ≥1 symptom at 3 weeks beyond the first symptom onset or positive diagnosis, whichever comes first. The secondary end point is chronic COVID-19, defined as ≥1 symptom at 12 weeks beyond the first symptom onset or positive diagnosis. Participants must be willing and able to consent to participate in the study and adhere to study procedures for 6 months. The first patient was enrolled in October 2021. The estimated year for publishing the study results is 2025. This is a fully decentralized study investigating PASC using wearable devices to collect physiological parameters and patient-reported outcomes. The study will shed light on the duration and symptom manifestation of PASC in nonhospitalized patient subgroups and is an exemplar of the use of wearables as population-level monitoring health tools for communicable diseases. ClinicalTrials.gov NCT04927442; https://clinicaltrials.gov/study/NCT04927442. DERR1-10.2196/57382.

Towards an understanding of the ethics of electronic consent in clinical trials

There are good practical reasons to use electronic consent (e-consent) in randomised trials, especially when conducting large-scale clinical trials to answer population-level health research questions. However, determining ethical reasons for e-consent is not so clear and depends on a proper understanding of what e-consent means when used in clinical trials and its ethical significance. Here we focus on four features of ethical significance which give rise to a range of ethical considerations relating to e-consent and merit further focused ethics research.

Associations of residential greenness with behavioural, physical, and mental health: a Hong Kong study during the fifth wave of COVID-19 pandemic

ABSTRACT Exposure to greenspace is protective of physical and mental health, but its role during the COVID-19 pandemic is unclear. We examined cross-sectional associations of residential greenness with behavioural, physical, and mental health outcomes during the fifth wave of COVID-19 in Hong Kong. A questionnaire of n = 160 participants assessed frequency of greenspace visits, physical activity from the International Physical Activity Questionnaire, and physical and mental health based on the 12-item Short-Form Health Survey. Residential greenspace was measured in terms of number of greenspace within a 400-m buffer, proximity to greenspace, and Landsat-derived Normalised Difference Vegetation Index as a metric of quality. Residing in higher greenness tertiles within 400 m was associated with higher odds of at least weekly visits to greenspace (OR = 3.23, 95% CI: 1.20-8.69 for the middle and OR = 5.62; 95% CI: 2.08-15.21 for highest tertiles) relative to the lowest exposure tertile. The count of residential greenspace was protectively associated with physical and mental health outcomes. The beneficial association between greenness and weekly usage remained robust at 500 m and was significant only among private housing residents. Policies towards scaling up and optimising residential greenness may constitute important public health interventions for enhancing population-level health and resilience during societal shocks

SARS-CoV-2 seroprevalence in people living with HIV in South Sudan

ObjectivesThe burden of SARS-CoV-2 infection in people living with HIV (PLHIV) in South Sudan is unknown. MethodsWe conducted a cross-sectional seroprevalence survey of SARS-CoV-2 immunoglobulin (Ig) G antibodies and other diseases of public health importance (strongyloidiasis, toxoplasmosis) in PLHIV in South Sudan during April 1, 2020-April 30, 2022. We used a multiplex SARS-CoV-2 immunoassay to detect IgG antibodies targeting the SARS-CoV-2 spike, receptor binding domain, and nucelocapsid (N) proteins, and antigens for other pathogens (Strongyloides stercoralis and Toxoplasma gondii). ResultsAmong 3518 samples tested, seroprevalence of IgG antibodies to SARS-CoV-2 spike protein and receptor binding domain 591 and nucleocapsid ranged from 1.4% (95% confidence interval [CI]: 0.9-2.1%) in April-June 2020 to 53.3% (95% CI: 49.5-57.1%) in January-March 2022. The prevalence of S. stercoralis IgG ranged between 27.3% (95% CI: 23.4-31.5%) in October-December 2021 and 47.2% (95% CI: 37.8-56.8%) in July-September 2021, and, for T. gondii IgG, prevalence ranged from 15.5% (95% CI: 13.3-17.9%) in April-June 2020 to 36.2% (95% CI: 27.4-46.2%) July-September 2021. ConclusionsBy early 2022, PLHIV in South Sudan had high rates of SARS-CoV-2 seropositivity. Surveillance of diseases of global health concern in PLHIV is crucial to estimate population-level exposure and inform public health responses.