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BackgroundThe aim of this study was to examine some psychometric characteristics of the Chilean-adapted version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT-24) (24) in a group of unselected children (community sample). This version was administered remotely through an online version during the pandemic period to caregivers of children, aged 18–24 months, registered in four primary care polyclinics of the Health Service Araucanía Sur, Chile.MethodsAn intentional non-probabilistic sampling was used. Three hundred and thirteen toddlers were examined. Participants completed an online version of the Q-CHAT-24 which was disseminated through the REDCap platform. Evidence of reliability through internal consistency and evidence of predictive validity through ROC curve analysis were realized.ResultsThe mean age of the children evaluated was 21.16 months. The Shapiro-Wilk test revealed that Q-CHAT-24 scores was normally distributed. 71 cases (23.12%) scored 38 points or more on the Q-CHAT-24, qualifying as Autistic Risk. 48 cases (15.63%) were confirmed as autistic through the ADOS-2 Module T. All items were positively correlated with Q-CHAT-24 total score. All items were positively correlated with Q-CHAT-24 total score. Internal consistency was acceptable for the Q-CHAT-24 (Cronbach ́s α=0.78). The internal consistencies were analyzed for the Q-CHAT-24 Factors, and they were good for factor 1 “Communication and Social Interaction” (Cronbach ́s α=0.85) and acceptable for factor 2 “Restrictive and Repetitive Patterns” (Cronbach ́s α=0.74). Receiver operating characteristic (ROC) curve analyses were performed. The AUC values were 0.93 with statistical significance (p

Background: Understanding discrepancies in mental health and substance use treatment utilization can help identify inequities in access to health services. We investigate mental health and substance use treatment utilization as function of demographic and social determinants, as well as pre-existing mental health and substance use disorders. Methods: In this repeated cross-sectional study, we used the 2017–2019 National Survey on Drug Use and Health data on US adults above age 18. Two logistic regression models were conducted, using predictors of age, gender, race/Hispanicity, sexual identity, education, insurance, family income, and past year mental health and substance use disorders, with outcomes of mental health or substance use treatment utilization. Weighted estimates of substance use disorders and insurance types and Pearson's correlation tests of vulnerability among age, gender, and treatment type were reported. Findings: Racial minorities, uninsured populations, sexual minorities, and females had lower odds of receiving mental health treatment, while older populations, lower income groups, and dual eligible enrollees had higher odds. Individuals with substance use disorders but no mental illness had higher odds of receiving mental health treatment. Those utilizing mental health treatment were mostly of high income, privately insured, and using cannabis, cocaine, and opioids. Older populations, men, and Medicaid only enrollees had higher odds of receiving substance use disorder treatment, whereas racial minorities had lower odds. Distribution of income, insurance type, and substance use were more widespread than mental health treatment. Interpretation: Mental health treatment can be used as an avenue for substance use treatment, particularly opioid use disorders. It is important to target vulnerable populations, like racial minorities and uninsured populations to improve access to mental health and substance use treatment.

BackgroundDigital therapeutics are patient-facing digital health interventions that can significantly alter the health care landscape. Despite digital therapeutics being used to successfully treat a range of conditions, their uptake in health systems remains limited. Understanding the full spectrum of uptake factors is essential to identify ways in which policy makers and providers can facilitate the adoption of effective digital therapeutics within a health system, as well as the steps developers can take to assist in the deployment of products. ObjectiveIn this review, we aimed to map the most frequently discussed factors that determine the integration of digital therapeutics into health systems and practical use of digital therapeutics by patients and professionals. MethodsA scoping review was conducted in MEDLINE, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. Relevant data were extracted and synthesized using a thematic analysis. ResultsWe identified 35,541 academic and 221 gray literature reports, with 244 (0.69%) included in the review, covering 35 countries. Overall, 85 factors that can impact the uptake of digital therapeutics were extracted and pooled into 5 categories: policy and system, patient characteristics, properties of digital therapeutics, characteristics of health professionals, and outcomes. The need for a regulatory framework for digital therapeutics was the most stated factor at the policy level. Demographic characteristics formed the most iterated patient-related factor, whereas digital literacy was considered the most important factor for health professionals. Among the properties of digital therapeutics, their interoperability across the broader health system was most emphasized. Finally, the ability to expand access to health care was the most frequently stated outcome measure. ConclusionsThe map of factors developed in this review offers a multistakeholder approach to recognizing the uptake factors of digital therapeutics in the health care pathway and provides an analytical tool for policy makers to assess their health system’s readiness for digital therapeutics.

Background and Aims: New psychoactive substances (NPS) pose challenges not only due to their harms to users but also because they are difficult to monitor with traditional epidemiologic methods. Wastewater-based epidemiology (WBE) offers a reliable method to assess drug-taking habits in different geographical settings and their evolution over time. The aim of this systematic review was to examine NPS preferences and trends across Europe. Methods: We searched electronic databases between September 5th to 30th, 2022, included OVID/Embase, PubMed, Scopus, and Web of Knowledge. Key search terms focused on NPS, WBE, prevalence, and geographic Europe. 18 articles were included in the systematic review. All studies were WBE studies, with 17 studies collecting samples from wastewater treatment plants, one collecting from pissoirs. Due to heterogeneity across studies, a meta-analysis was not performed. Results: Literature reviewed in this study showed a trend towards stimulant-type NPS use, with the United Kingdom showing highest detection frequency. The most detected chemical class of NPS were synthetic cathinones. Southern and Western Europe showed the largest variety of NPS detected. Metabolite detection ranged extensively across countries. Conclusion: This is the first systematic review to address types of new psychoactive substances present in wastewater in Europe. Gaps in literature point to a need for standardization in wastewater-based epidemiology so that drug policies and public health policies, including drug and harm reduction services, can be targeted to those NPS that are most widely used.

Background: In a time of unprecedented global change, the COVID-19 pandemic has led to a surge in demand of COVID-19 vaccines and related certifications. Mainly due to supply shortages, counterfeit vaccines, fake documentation, and alleged cures to illegal portfolios, have been offered on darkweb marketplaces (DWMs) with important public health consequences. We aimed to profile key DWMs and vendors by presenting some in-depth case studies. Methods: A non-systematic search for COVID-19 products was performed across 118 DWMs. Levels of activity, credibility, content, COVID-19 product listings, privacy protocols were among the features retrieved. Open web fora and other open web sources were also considered for further analysis of both functional and non functional DWMs. Collected data refers to the period between January 2020 and October 2021. Results: A total of 42 relevant listings sold by 24 vendors across eight DWMs were identified. Four of these markets were active and well-established at the time of the study with good levels of credibility. COVID-19 products were listed alongside other marketplace content. Vendors had a trusted profile, communicated in English language and accepted payments in cryptocurrencies (Monero or Bitcoin). Their geographical location included the USA, Asia and Europe. While COVID-19 related goods were mostly available for regional supply, other listings were also shipped worldwide. Interpretation: Findings emerging from this study rise important questions about the health safety of certain DWMs activities and encourage the development of targeted interventions to overcome such new and rapidly expanding public health threats. Funding: CovSaf, National Research centre on Privacy, Harm Reduction and Adversarial Influence Online (REPHRAIN), Commonwealth Fund.

Background: The aim of this study was to examine some psychometric characteristics of the Chilean-adapted version of the Quantitative Checklist for Autism in Toddlers (Q-CHAT-24) (24) in a group of unselected children (community sample). This version was administered remotely through an online version during the pandemic period to caregivers of children, aged 18– 24 months, registered in four primary care polyclinics of the Health Service Araucanıa Sur, Chile. ́ Methods: An intentional non-probabilistic sampling was used. Three hundred and thirteen toddlers were examined. Participants completed an online version of the Q-CHAT-24 which was disseminated through the REDCap platform. Evidence of reliability through internal consistency and evidence of predictive validity through ROC curve analysis were realized. Results: The mean age of the children evaluated was 21.16 months. The ShapiroWilk test revealed that Q-CHAT-24 scores was normally distributed. 71 cases (23.12%) scored 38 points or more on the Q-CHAT-24, qualifying as Autistic Risk. 48 cases (15.63%) were confirmed as autistic through the ADOS-2 Module T. All items were positively correlated with Q-CHAT-24 total score. All items were positively correlated with Q-CHAT-24 total score. Internal consistency was acceptable for the Q-CHAT-24 (Cronbach́ s a=0.78). The internal consistencies were analyzed for the Q-CHAT-24 Factors, and they were good for factor 1 “Communication and Social Interaction” (Cronbach́ s a=0.85) and acceptable for factor 2 “Restrictive and Repetitive Patterns” (Cronbach́ s a=0.74). Receiver operating characteristic (ROC) curve analyses were performed. The AUC values were 0.93 with statistical significance (p<0.01). For the cut-off point of 38, the Sensitivity, Specificity and Youden index values were 0.89, 0.8 and 0.7, respectively. The Positive Predictive Value (PPV) was 86% and the Negative Predictive Value (NPV) was 85%. Conclusions: In accordance with the objectives of this study, evidence of reliability and predictive validity was demonstrated for the Q-CHAT-24 in this Chilean population. More importantly, this study provides Sensitivity and Specificity data for a remote application version of an autism screening tool already validated in Chile. The implications of this have to do with the possibility of establishing a remote assessment system for children at risk of autism on a population scale. [ABSTRACT FROM AUTHOR]

Background: There is growing concern about how people with eating disorders are impacted by the widespread societal restructuring during the COVID-19 crisis. Aims: We aimed to examine how factors relating to the impact of the pandemic associate with eating disorders and quantify this relationship while adjusting for concurrent and longitudinal parameters of risk. Methods: We gathered demographic, behavioral and clinical data pre- and mid-pandemic as well as childhood trauma history from a longitudinal online survey of 489 adults (mean age 23.4 years) recruited from the Neuroscience in Psychiatry Network (NSPN). Using pre-pandemic (T1) and concurrent (T2) data we aimed to predict eating disorders at mid-pandemic (T2). We deployed hierarchical generalized logistic regression to ascertain the strength of longitudinal and concurrent associations. Results: Pre-pandemic eating disorder scores strongly associated with concurrent eating disorder (z = 5.93). More conflict at home mid-pandemic (z = 2.03), pre- (lower sensation seeking z = −2.58) and mid-pandemic (higher lack of perseverance z = 2.33) impulsivity traits also associated with mid-pandemic eating disorder. Conclusion: Conflict at home mid-pandemic and specific aspects of impulsiveness significantly associated with concurrent eating disorder when adjusted for pre-pandemic eating disorder symptoms, baseline demographics, behavioral traits, history of traumatic experiences and concurrent psychopathology. These results provide insight into the struggles of those suffering with eating disorders during the COVID-19 pandemic and highlight the importance of impulsiveness traits and the immediate family environment in their experience of illness during the pandemic.

Background: Chemsex refers to the use of drugs (e.g. mephedrone, gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL), methamphetamine, and ketamine) before or during sexual activity. Men who have sex with men (MSM) are a population in which chemsex engagement is prevalent. This poses risks of harm for mental and psychosocial health resulting in the use of healthcare services. This review aims to analyse the extent to which current prevention and harm reduction strategies concerning chemsex meet the healthcare needs of MSM who engage in chemsex in France, Germany, the Netherlands, Spain, and the United Kingdom. Methods: Published papers reporting prevention and harm reduction interventions concerning MSM who engage in chemsex were identified through PubMed and Scopus. By utilising a holistic care perspective, data was synthesised concerning social norms within the MSM community, experiences with care providers, healthcare needs, experienced barriers to seek care, and structural barriers to providing care. Results: Literature search identified 154 unique publications, of which 17 were included in the data synthesis. The cultural acceptance of drug use in both sexual and non-sexual contexts is high within the MSM community. Whereas there is a lack of awareness of chemsex-specific care by sexual health clinics (SHCs), standard drug and health clinics are often experienced negatively. The ability of SHCs to offer support tailored to the needs of MSM who engage in chemsex is often limited by lack of training or lack of referral chains. Conclusion: As the MSM community and especially MSM who engage in chemsex are quick to adapt to new drug trends, it is important to increase support system resilience for chemsex care. There is a need for training, interorganisational cooperation, and expertise sharing and awareness of quality chemsex services and information. Integrated chemsex care, rapid referral chains, and their evaluations are required to align provided care with healthcare preferences.

Introduction: Novel psychoactive substances (NPS) continue to pose challenges to law enforcement authorities, public health officers and policymakers as suppliers continuously adapt to control measures, thus remaining highly dynamic in introducing unpredictable and potentially toxic new substances into the drug market. Using a legal epidemiology approach, the aim of this study was to assess the effectiveness of NPS legal measures in preventing NPS use (legal prevention and control), as well as NPS-related intoxications and deaths (legal aetiology). Methods: We conducted a comparative analysis of legal instruments adopted at national level as a response to NPS by ten European countries between 2008 and 2019. The data collection process encompassed (i) a scoping review aimed at mapping out the current state of NPS-related legal measures, and (ii) the collection of nationally produced health data on three NPS-related health indicators (prevalence of use, acute intoxications and deaths). Results: Based on both the legal approaches and the regulatory model adopted by countries a five-elements typology was elaborated. Implemented measures – particularly individual listing – may be relatively effective in preventing NPS use, at least in the short-term. However, they are also very likely to affect the purity and potency of substances, which may have an indirect negative impact on users’ health. In fact, an increase in NPS-related poisoning episodes and deaths has been observed in most of the countries having introduced control measures, regardless the regulatory model adopted. Conclusions: Policy responses to NPS implemented across Europe have not been markedly effective in deterring their use nor in preventing health harms. Therefore, there is a need for innovative initiatives to regulate drug markets that go beyond law enforcement. Considering scientific evidence on underlying factors leading to the use of psychoactive substances may better inform policy responses to address users’ motivations while reducing their exposure to health risks.

Background: Community health workers (CHWs) are central to India's strategy for reaching the Sustainable Development Goals around maternal and child health. Despite India's significant investment in these programs, few studies have analyzed the effect of CHWs across India. Objective: This study aims to analyze multiple types of CHWs and their impact on a broad range of antenatal and infant health outcomes across India. Methods: In this population-based cross-sectional study, we analyzed data of women interviewed by the most recent 2015–2016 National Family Health Survey-4 (NFHS-4) in India. This study performed multiple variable regressions to examine the effect of receiving ANC during pregnancy from 1) any CHW and 2) by specific type of CHW - Accredited Social Health Activist (ASHA), Anganwadi Worker (AWW), and Community/Village Health Worker (defined in Table 1) on antenatal and infant health outcomes. Results: Of 166,498 women, 14.2% received ANC from any CHW with specifically 5.9% receiving from ASHAs, 10.2% receiving from AWWs, and 0.5% receiving from Community/Village Health Workers. Women who received ANC from an ASHA had increased ANC utilization (OR 1.77; 95% CI 1.65, 1.91) as well as quality (IRR 1.06; 95% CI 1.05, 1.08), increased early initiation of breast feeding (OR 1.20; 95% CI 1.12, 1.29), and decreased one-year mortality (OR 0.75; 95% CI 0.63, 0.88). Women who received ANC from an AWW had increased ANC utilization (OR 2.24; 95% CI 2.12, 2.37) as well as quality (IRR 1.07, 95% CI 1.06, 1.08) and increased early initiation of breast feeding (OR 1.30; 95% CI 1.26, 1.40). Conclusion: Receiving ANC from ASHAs and AWWs is associated with improved ANC utilization, ANC quality, early initiation of breastfeeding and the key outcome of reduced infant mortality.

Abstract Introduction The universal right to education for people with disabilities has been highlighted by the Universal Declaration on Human Rights and the Convention on the Rights of Persons with Disabilities. In this paper, we mapped policies addressing the right to education and special education needs of autistic children in Denmark, Sweden, and Finland. Methods A policy path analysis was carried out using a scoping review as an underlying framework for data gathering. Policy mapping was performed independently by both lead authors to increase reliability. Results and discussion The values of the Universal Declaration of Human Rights and the Convention on the Rights of Persons with Disabilities have been closely translated into the respective education systems of the countries under study, offering special education needs services and support in mainstream education with the aim of including as many children into mainstream education as possible. Even though the education systems are comparable, the approaches between the countries under study are slightly different. Denmark and Sweden have passed several policies specifically geared towards special education needs, while Finland incorporates this more in general education policy. Conclusion All countries under study have incorporated the values of the Universal Declaration of Human Rights and the Convention on the Rights of Persons with Disabilities in their respective education systems while emphasising the need to include as many children in the mainstream system as possible.

Abstract Introduction In recent years, the universal right to education has been emphasised by the Universal Declaration on Human Rights and the Convention on the Rights of Persons with Disabilities. In this paper, we mapped policies relevant to special education needs and parental involvement of children with autism at an international level and in the Netherlands, Germany and Belgium. Methods A policy path analysis was performed using a scoping review as an underlying methodological framework. This allowed for a rapid gathering of available data from which a timeline of adopted policies was derived. Results and discussion Internationally, the universal right to education has been reinforced repeatedly and the values of the Universal Declaration of Human Rights have been reiterated with every reinforcement. Also, the additional support that a child with special education needs requires is acknowledged and measures are taken to facilitate access to any education for all children. There are slight cross-country differences between the countries under study, attributable to differences in national regulation of education. However, all countries have progressed to a state where the right to education for all children is integrated on a policy level and measures are taken to enable children with special needs to participate in education. Recently, an attempt to implement a form of inclusive education was made as a form of special needs provision. Nevertheless, nowhere has this been implemented successfully yet. Conclusion The Universal Declaration of Human Rights was a critical juncture in international policy and created an environment where the universal right to education has been implemented for all children in the countries under study.

Abstract Background Unmet need for mental health services remains high in the United States and is disproportionately concentrated in some groups. The scale and nature of these disparities have not been fully elucidated and bear further scrutiny. As such, in this study, we examine the demographic, socioeconomic, and health correlates of unmet need for mental health treatment as well as the reasons for unmet need. Methods We draw upon the National Survey for Drug Use and Health (NSDUH) from 2002 to 16 for adults aged 18 and over in the United States (n = 579,017). Using multivariable logistic regression, we simultaneously model the demographic, socioeconomic, and health correlates of unmet need for mental health treatment from 2002 to 16. We also analyse the reasons for unmet need expressed by these populations, reasons which include cost, perceived stigma, minimisation of symptoms, low perceived effectiveness of treatment, and structural barriers. Results Major characteristics associated with increased odds of unmet need include past year substance abuse or dependence (other than hallucinogens and sedatives), fair, poor, or very poor health, being female, and an educational attainment of college or higher. With respect to reasons for unmet need, cost was most often cited, followed by perceived stigma, structural barriers, and minimisation. Characteristics associated with increased odds of indicating cost as a reason for unmet need include: being uninsured or aged 26–35. Minimisation and low perceived effectiveness are mentioned by high-income persons as reasons for unmet need. College-educated persons and women had higher odds of citing structural barriers as a reason for unmet need. Conclusions The correlates and causes of unmet need highlight the intersectionality of individual health needs with implications on addressing inequities in mental health policy and practice.

[This corrects the article DOI: 10.1371/journal.pone.0241056.].

Background: Hepatitis C virus (HCV) infection is a leading cause of hepatitis C, liver cancer, and cirrhosis. It is treatable with directing acting antivrials (DAAs), yet still accounts for over 580,000 global deaths annually. Due to the nature of transmission and particular risk factors, men living with HIV who have sex with other men (HIV+ MSM) are disportionately burdened. Whilst HCV is a statutorily notifiable disaease in England and a virtually complete registry exists, data specific to MSM are not captured, leaving gaps in our knowledge of HCV trends among HIV+ MSM. Methods: This paper aims to investigate the HCV prevalence and incidence among HIV+ MSM in England through a systematic review of academic literature. Results: The systematic review resulted in six articles. Evidence suggests that incidence has generally risen between 2002-2015 and declined between 2015-2018, which may be attributed to the introduction of DAAs. The range of reported prevalences varied from 2.2%-9.9% , the most recent estimate being 4.24% in 2018. Conclusions: This review's deficiency is the non-existent record of behavioural risk factors across the studies. Most studies recruited HIV+ MSM from HIV clinics, an arguably robust sampling method considering that 90% of those living with HIV in England are engaged in care at an HIV clinic. The gaps in the academic literature and national surveillance for HCV among HIV+ MSM demonstrate this group to be disproportionately under-studied. National surveillance ought to record HCV cases and risk factors specific to HIV+ MSM to better inform interventions.

The Soviet occupation of the Baltic States followed by joining the United Nations (UN) and European Union make these countries an interesting point of comparison in the development of autism and education policy. This study investigates how policies changed following the transition and how the right and access to education are facilitated for autistic children by performing a path dependence analysis. All Baltic States created new education policies following the transition out of the Soviet era, with their accession to the UN and their appetite to follow internationally available guidance. The right to education for all children in was adopted in all education systems. Education facilities for children with disabilities were implemented in all countries. Afterward, all countries started toward the development of more inclusive systems. Nevertheless, the majority of policies did not specify for autism, yet covered special education needs in general. A development in Latvia should be noted, where various special education needs are outlined in national policy, along with provisions and professional assistance required to address them in mainstream or special classrooms. Ultimately, education policy flourished after the transition. Their development caught up to other European Union countries and they are currently working on implementing inclusive education.

Although people are living longer, there is no discernible pattern about the quality of life in an increasing lifespan. This restricts our capacity to predict and prepare for the consequences of population ageing. Accordingly, we propose a population ageing indicator that combines demographic and disability prevalence data through a characteristics approach and explore different scenarios to account for uncertainty in life quality projections. Our results, available for 186 countries, show that countries that rank older under conventional chronological ageing measures may rank younger under our qualitative measure. Additionally, we find substantial differences in our projections depending on different health assumptions, demonstrating the risk of using ageing indicators that make implicit assumptions about health characteristics.

OBJECTIVE:To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers. METHODS:Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007-16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007-16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment. RESULTS:Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035). CONCLUSIONS:Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.

IntroductionAs Novel psychoactive substances (NPS) are conceived to mimic the effects of common illicit drugs, they represent a serious public health challenge due to the spike in intoxications and fatalities that have been linked to their use. This study aims to provide epidemiological data on NPS use in the USA, determining lifetime prevalence of use and defining demographic, socioeconomic, drug use patterns and mental health correlates.MethodsThis study uses secondary data from the US National Survey on Drug Use and Health (NSDUH), which is a large cross-sectional population-based survey carried out annually in the USA. We analysed data from 2007-14 (N = 307,935) using bivariate descriptive analysis and binary logistic regression to calculate prevalence and determine factors underlying NPS consumption. Adjusted odds ratios (OR) with 95% CI's were calculated for a set of selected independent variables.Results and discussionOur analysis NSDUH from 2007-14 highlights an increase in NPS use among adults, especially among white young men aged 18 to 25. Although the level of education of NPS users was relatively higher as compared to non-users, NPS users seemed to have a less wealthy situation. However, socioeconomic vulnerability appeared to be less important than mental health issues as a correlate to NPS use. NPS users seem to have followed a pattern of polysubstance use throughout their life, which involves both traditional illicit drugs and classic synthetic drugs. As NPS use seemed to be more prevalent among people having mental health issues, the rise in their use may have a negative impact on population mental health outcomes.ConclusionFurther comparative research on trends in NPS use and potential public health responses would be instrumental for developing appropriate health interventions, including drug checking, education for users and training for healthcare professionals working both within emergency wards and in/outpatient addiction and mental health services.

Abstract Background In Germany and Chile, substitutive private health insurance has been shaped by its co-existence with statutory social health insurance. Despite differences in the way choice is available to users in the health insurance regimes of Chile and Germany, the way in which each country has managed choice between private health insurance and statutory social health insurance provides a unique opportunity to comparatively assess the consequences of such an arrangement that has been previously underexamined. Methods We conducted a Most Similar Systems Design comparative policy analysis of the co-occurring private health insurance and statutory social health insurance systems in Germany and Chile. We describe and review the origins and development of the German and Chilean health care insurance systems with an emphasis on the substitutive co-existence between private health insurance and statutory social health insurance. We provide a critique of the market performance of the private health insurance regime in each country followed by a comparative assessment of the impact of private health insurance on financial protection, equity, and risk segmentation. Results Segmentation of insurance markets in both Germany and Chile has had significant consequences for equity, fairness, and financial protection. Due to market failures in health insurance and differences in the regulatory frameworks governing public and private insurers, the choice of public or private coverage has produced strong incentives for private insurers to select for risks, compromising equity in health care funding, heightening the financial risk borne by public insurers and lowering incentives for private insurers to operate efficiently. Conclusions The degree of conflict arising from the substitutive parallel private health insurance system and the statutory social health insurance system varies between Germany and Chile, though policy goals remain similar. Recent reforms in both countries have attempted to improve the financial protection of the privately insured through regulation; nevertheless, concerns about risk segmentation remain largely unresolved.

BACKGROUND:Access to adequate treatment for opioid use disorder (OUD) has been a high priority among American policymakers. Elucidation of the sociodemographic and institutional differences associated with the use, or lack thereof, of opioid agonist therapy (OAT) provides greater clarity on who receives OAT. Timely access to care is a further consideration and bears scrutiny as well. METHODS:We draw upon data from the Treatment Episode Data Set-Admissions (TEDS-A) to analyse the relationship between sociodemographic and institutional characteristics and the receipt of opioid agonist treatments and time waiting to enter treatment. RESULTS:Estimates from logistic regression models highlight certain groups which show lower odds of receipt of OAT, including those in precarious housing arrangements, those unemployed or not otherwise in the labor force, and those referred by drug abuse care providers, educational institutions, employers, and the criminal justice system. Groups which showed higher odds of waiting over a week to enter treatment included those who were separated, divorced, or widowed, those working part-time, and those referred by drug abuse care providers, employers, and the criminal justice system. CONCLUSION:Given the efficacy of OAT and the adverse outcomes associated with long waiting times, coordinated effort is needed to understand why these differences persist and how they may be addressed through appropriate policy responses.

IntroductionOpioids are one of the most important and effective drug classes in pain medicine with a key role in most medical fields. The increase of opioid prescription over time has led to higher numbers of prescription opioid misuse, abuse and opioid-related deaths in most developed OECD (Organisation for Economic Co-operation and Development) countries around the world. Whilst reliable data on the prevalence of opioid treatment is accessible for many countries, data on Germany specifically is still scarce. Considering Germany being the largest country in the European Union, the lack of evidence-based strategies from long-term studies is crucial. The aim of this work is to review and summarise relevant published literature on the prevalence of opioid prescription in Germany to adequately inform health policy strategies.MethodsA systematic review of the epidemiology of opioid prescription in Germany was conducted, searching PubMed and Web of Science. Eligibility criteria were defined prior to conducting the search. Literature concerning Germany, published in English and German was included and the search was replicated by three independent researchers. Two levels of screening were employed. Disagreement was resolved by face-to-face discussion, leading to a consensus judgement.ResultsOur electronic search yielded 735 articles. Reviewing titles and abstracts yielded 19 relevant articles. Three authors examined each article's full text more closely and determined that twelve papers should be included. Of the twelve identified studies-with publication dates ranging from 1985 to 2016-six were retrospective cross-sectional studies and six were retrospective repeated-measures cross-sectional studies. Sample sizes ranged from 92,842 to ≈ 11,000,000 participants. Data sources of included studies showed vast heterogeneity. The reviewed literature suggested an increase in the number of patients with opioid prescriptions and defined daily doses of opioids per recipient in Germany over time. The majority of opioid prescriptions was used for patients with non-cancer pain. Opioid use was more common in older people, women and in the north of Germany. Fentanyl was shown to be the most prescribed strong opioid in outpatient settings in Germany, despite not being the first-line choice for chronic pain conditions. All data published before 2000-but none of the more recent studies-suggested an insufficient treatment of pain using opioids. There were no signs for a current opioid epidemic in Germany.ConclusionsDespite some limitations of the review and the heterogeneity of studies, it can be stated that the number of opioid prescriptions overall as well as the number of people receiving opioid treatment have increased over time. Most prescriptions were found to be for strong opioids and patients with non-cancer pain. Even though patterns of opioid prescription follow trends observed in other developed countries, there are no signs of an opioid epidemic in Germany. Therefore, this review could currently not find a need for urgent health policy interventions regarding opioid prescription practices. However, critical gaps in the literature remain and more research is needed to make more reliable judgements.

IntroductionThe rapid rise in trade and use of NPS and the lack of information concerning their potential toxicity pose serious challenges to public health authorities across the world. Policy measures towards NPS taken so far have a special focus on their legal status, while the implementation of a public health strategy seems to be still missing. The aim of this study is to perform a general assessment of NPS-related policy (including regulatory measures and public health strategies) implemented by six European countries: Portugal, the Netherlands, Czech Republic, Poland, the United Kingdom and Sweden.MethodsSix EU countries were included in this scoping review study. Drug policies (including legal responses and public health strategies) were analysed. UNODC drug policy classification system was used as a benchmark, while path dependency approach was used for data analysis; a net of inter-dependencies between international, EU and national policies was highlighted.Results and discussionThe countries included in this study can be placed in a wide spectrum according to their formulation of drug policy, from Portugal and the UK that have specific legal responses to NPS but have differently focused on harm reduction strategies at one end, to Sweden whose drug-free society goal is not translated into a specific regulation of NPS at the other end.ConclusionThe findings of the study reveal limited development towards harmonisation of national drug policies-particularly with regard to NPS. To tackle the challenge presented by NPS, EU Member states have formulated legislation and public health strategies independently. National approaches to NPS are therefore in line with their already existing drug policies, reflecting cultural values towards substance abuse and national political interests, while the homogenization at an international level has so far mostly been focused on law enforcement and drugs use preventive strategies.

BackgroundIn 2017, more than 1.1 million children were living with type 1 diabetes mellitus (T1DM) globally. The goal in paediatric diabetes therapy is reaching optimal glycaemic control as early as possible in order to avoid complications and early mortality without compromising the quality of life (QoL) of children. Several different insulin regimens are available for T1DM patients to reach this goal.AimsThis review set out to analyse whether continuous subcutaneous insulin infusion (CSII) regimens are superior to multiple daily injection (MDI) therapy in T1DM youth regarding QoL. Additionally, it assessed glycaemic control and adverse events as secondary outcomes and discussed potential future public health implications and justifications for using CSII as a first-line therapy in diabetic youth.MethodsA systematic review and random effects meta-analysis was performed on studies investigating the association between QoL and diabetes treatment regimen. Differences in adverse event rates between groups were analysed using a Mann-Whitney U test. Lastly, differences in glycaemic control were assessed using a random effects meta-analysis.ResultsQoL and glycaemic control was significantly better in CSII subjects at baseline and follow-up. No significant differences in adverse events were found between study groups. No significant changes over time could be shown for either QoL or glycaemic control.ConclusionCSII proved to provide similar or slightly better outcomes in all analysed fields. This is consistent with previous research. However, to make credible recommendations, better-designed studies are needed to investigate the impact of CSII in children.

IntroductionIn a society that perpetuates the strive for a perfect appearance, a fit body has become synonymous with success, but simultaneously hard to achieve. This represents a fertile ground for the development of Exercise Addiction (EA) alongside other disorders, such as Body Dysmorphic Disorder (BDD). This study aims to explore the diffusion of EA in fitness settings in the United Kingdom, Italy, Netherlands, Hungary and the previously unexplored association with appearance anxiety, BDD, self-esteem and the use of fitness supplements.MethodsA large cross-sectional sample (N = 1711) was surveyed in fitness settings using the Exercise Addiction Inventory (EAI), Appearance Anxiety Inventory (AAI) and Rosenberg's Self Esteem Scale (RSE) in addition to questions surrounding the use of fitness supplements.ResultsCompulsive exercise, appearance anxiety and low self-esteem were present in this sample according to the psychometric measures used (EAI, AAI, RSE). 11.7% scored over the cut off for EA, with alarming peaks in the Netherlands (20.9%) and the United Kingdom (16.1%). 38.5% were found at risk of BDD, mainly female (47.2%). 39.8% used fitness enhancing supplements without medical consultation (95.5%). This cohort of supplement users scored higher in both EAI and AAI. The logistic regression model revealed a strong association between the consumption of sport products and the level of EA across the sample with an odds ratio (OR) of 3.03. Other co-variable factors among female were appearance anxiety (AAI; OR 1.59) and to a lesser extent self-esteem (RSE) (OR 1.08).ConclusionsThis study identified a high risk of EA, appearance anxiety and BDD amongst a cohort of gym users internationally. The previously-unexplored association between these disorders and the unsupervised use of a variety of fitness products, including illicit drugs, highlights the need for informed and integrated responses targeting such vulnerable individuals.

INTRODUCTION:Autistic people may have different educational needs that need to be met to allow them to develop their full potential. Education and disability policies remain within the competence of EU Member States, with current educational standards and provisions for autistic people implemented locally. This scoping review aims to map EU and national special education policies with the goal of scoping the level of fulfilment of the right to education of autistic people. METHODS:Four EU countries (United Kingdom, France, Poland and Spain) were included in this scoping review study. Governmental policies in the field of education, special education needs and disability law were included. Path dependency framework was used for data analysis; a net of inter-dependencies between international, EU and national policies was created. RESULTS AND DISCUSSION:Each country created policies where the right to free education without discrimination is provided. Poland does not have an autism specific strategy, whereas the United Kingdom, France and Spain have policies specifically designed for autistic individuals. Within the United Kingdom, all countries created different autism plans, nevertheless all aim to reach the same goal-inclusive education for autistic children that leads to the development of their full potential. CONCLUSION:Policy-making across Europe in the field of education has been changing through the years in favour of autistic people. Today their rights are noticed and considered, but there is still room for improvement. Results showed that approaches and policies vastly differ between countries, more Member States should be analysed in a similar manner to gain a broader and clearer view with a special focus on disability rights in Central and Eastern Europe.

BACKGROUND:The social and economic consequences of the global financial crisis (GFC) of 2007-9 has had serious impacts on population health, economic prospects, and overall wellbeing in all generations, particularly Millennials, Generation X, and Baby Boomers. The ways in which intergenerational inequality and global economic crises have affected population health, particularly with respect to excessive drinking and substance use in disadvantaged population groups has been understudied. Consequently, in this article, we seek to characterise the effects of the GFC on national trends in binge alcohol and substance use among Millennials, Generation X, and Baby Boomers. By doing so, we aim to contribute to a fuller understanding of the ways in which socioeconomic disadvantage engendered by the GFC has disparately affected the wellbeing of these generational cohorts. METHODS AND FINDINGS:We present results from National Survey on Drug Use and Health from 2007-16 to characterise binge alcohol and substance use among different generational cohorts in the United States during and after the GFC. Bivariate descriptive analysis and maximum-likelihood logit regressions focused on: (a) individual substances and binge drinking, (b) poly-use and (c) any use to simultaneously model how socioeconomic, demographic, and health characteristics were related to past-month substance use and to report the social, economic, and demographic correlates of substance use. Socioeconomic vulnerability was captured on a five-point scale comprised of: (1) health insurance status, (2) government assistance, (3) income, (4) self rated health, and (5) employment status. Millennials showed generally higher risk of binge alcohol and substance use during 2007-16 than Generation X, while Baby Boomers generally exhibited lower risk. Comparison of individual and poly-use patterns for the birth cohorts before and after reveals: Millennials were at significantly increased risk of use of binge alcohol (AOR = 1.51; 95% CI = 1.46-1.56), cocaine (AOR = 1.19; 95% CI = 1.03-1.37), heroin (AOR = 1.39; 95% CI = 1.01-1.91), and oxycontin (AOR = 2.33; 95% CI = 1.74-3.12) than Gen X while Baby Boomers were at significantly reduced risk of all substances. Nevertheless, Millennials were at significantly reduced risk of crack use (AOR = 0.33; 95% CI = 0.25-0.43) and poly-use (AOR = 0.56; 95% CI = 0.45-0.70) compared to Gen X. These differences may be related to measures of austerity and socioeconomic vulnerability. Millennials exhibited the highest vulnerability related to austerity with an average vulnerability score of 0.97 (95% CI = 0.96-0.98) while Baby Boomers exhibited the lowest average vulnerability score of 0.65 (95% CI = 0.64-0.66) with Generation X in between with 0.72 (95% CI = 0.71-0.73). Increased social and economic vulnerability after the 2007 crisis is strongly associated with higher rates of substance use in all generations. CONCLUSION:Millennials have been especially affected by socioeconomic changes associated with the GFC as reflected by their heightened vulnerability and increased use of binge alcohol and other substances compared to preceding generations. These findings suggest that attention is needed to address disparities in socioeconomic vulnerability, relationships to substance use and overall mental health of Millennials to mitigate the potential long term negative impacts of the GFC. In the context of a continuing international opioid and heroin crisis, the ways in which Millennials have been differentially affected warrants much greater attention both from policymakers and from researchers.