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If we considered them as separate countries, the per capita COVID-19 cases in North Dakota would make the state one of the two countries in the world with the highest number of COVID-19 cases;by contrast, Hawaii's case rate positions it in the range of about 85th on the global list of countries with COVID-19.2 These differences will, and undoubtedly should, occasion substantial consideration of the factors, both preexisting and concurrent with the pandemic, that brought about these differences. HEALTH HETEROGENEITY By way of example, in a review of trends in the US burden of disease across states between 1990 and 2016, Mokdad et al. found, consistent with previous analyses, substantial variability across states in a range of health indicators.3 There was a 6.6-year difference in life expectancy at birth in 2016 between the state with the highest (Hawaii) versus the lowest (Mississippi) life expectancy. [...]focusing on five leading causes of death, the Centers for Disease Control and Prevention showed that improving all states to the levels of the healthiest states could annually prevent more than 90 000 cases of premature heart disease, 84000 cases of cancer, 28000 cases of chronic lower respiratory disease, 16 000 cases of stroke, and 36000 cases of unintentional injury deaths.6 A concrete example of how interstate variability in the forces that generate health operate is offered in the article by Baugher et al. in the April issue of AJPH.7 The authors focused on the HIV epidemic and on the factors that may be associated with reduced uptake of preexposure prophylaxis, which can protect against HIV.

Atmospheric transport of fine particulate matter (PM2.5), the leading environmental risk factor for public health, is estimated to exert substantial transboundary effects at present. During the past several decades, human-produced pollutant emissions have undergone drastic and regionally distinctive changes, yet it remains unclear about the resulting global transboundary health impacts. Here we show that between 1950 and 2014, global anthropogenic PM2.5 has led to 185.7 million premature deaths cumulatively, including about 14% from transboundary pollution. Among four country groups at different affluence levels, on a basis of per capita contribution to transboundary mortality, a richer region tends to exert severer cumulative health externality, with the poorest bearing the worst net externality after contrasting import and export of pollution mortality. The temporal changes in transboundary mortality and cross-regional inequality are substantial. Effort to reduce PM2.5-related transboundary mortality should seek international collaborative strategies that account for historical responsibility and inequality.

OBJECTIVES This study aimed to evaluate the most updated worldwide distribution, risk factors, and temporal trends of cervical cancer for different countries and age groups. METHODS The Global Cancer Observatory database was retrieved for the age-standardized rates (ASRs, per 100,000 persons) for incidence and mortality of cervical cancer in 2018. The associations with risk factors were examined by multivariable regression analysis, adjusting for human development index (HDI) and gross domestic products (GDP) per capita. Joinpoint regression analysis was used to calculate the 10-year annual average percent change (AAPC) for incidence and mortality. RESULTS A total of 568,847 new cases (ASR, 13.1) and 311,365 deaths (ASR, 6.9) of cervical cancer were reported globally in 2018. The highest incidence and mortality were observed in Southern Africa (ASRs, 43.1 and 20.0) and countries with low HDI (ASRs, 29.8 and 23.0). Countries with higher incidence and mortality had lower HDI (β = -8.19, 95% CI -11.32 to -5.06, p

INTRODUCTION Singapore has had three medical schools since 2013. We undertook a cross-sectional quantitative national survey to determine the financial impact of medical education on medical students in Singapore. METHODS All 1,829 medical students in Singapore were invited to participate in this study. Information on demographics, financial aid utilisation and outside work was collected and analysed. RESULTS 1,241 (67.9%) of 1,829 students participated in the survey. While the overall proportion of students from households with monthly incomes < SGD 3,000 was only 21.2% compared to the national figure of 31.4%, 85.4% of medical students expected to graduate with debts > SGD 75,000. There were significant differences in per capita incomes among the schools, with 54.5%, 23.3% and 7.8% of Duke-NUS Medical School (Duke-NUS), NUS Yong Loo Lin School of Medicine (NUS Medicine) and Lee Kong Chian School of Medicine (LKCMedicine) students, respectively, reporting a per capita income of < SGD 1,000 (p < 0.001). There were significant differences in financial support: 75.0%, 34.1% and 38.8% of Duke-NUS, NUS Medicine and LKCMedicine students, respectively, received financial aid (p < 0.001). The top reasons for not applying for aid included a troublesome application process (21.4%) and the perception that it would be too difficult to obtain (21.0%). CONCLUSION Students in the three medical schools in Singapore differ in their financial needs and levels of financial support received. A national approach to funding medical education may be needed to ensure that financial burdens do not hamper the optimal training of doctors for Singapore’s future.

Although lung cancer screening with low-dose CT (LDCT) can reduce lung cancer mortality by 20%, without an appropriate eligibility criteria, it may result in a waste of medical resources and a degree of unnecessary damage to participants' health. This study aims to give the optimal screening strategy in China based on cost-effectiveness analysis on pros and cons of different situations. From the perspective of primary healthcare system, a Markov model was built to simulate LDCT screening of 100,000 heavy smokers (>30 pack years) aged 40 in different situations. Model parameters mainly came from screening programs conducted in China and other countries, official public data, and published literature. Two indicators of primary outcome, incremental cost-effectiveness ratio (ICER) and net health benefits (NHB), were compared with those of no screening. Sensitivity analysis was conducted to evaluate model uncertainties. We defined the optimal strategy as the one with both acceptable cost effectiveness and maximal NHB. Base-case analysis results showed that for all screening strategies, ICERs were less than three times of GDP per capita. As for NHB results, it showed that when the willingness to pay for screening was less than three times of GPD per capita, the largest NHB was obtained in the strategy which started screening at 50 years old and this strategy showed stable performance in univariate and probabilistic sensitivity as well. Prevention Relevance: LDCT screening is cost effective in heavy smokers in China, and the optimal age to start screening is suggested to be 50 years old.

Unintentional and violence-related injury fatalities, including suicide, homicide, overdoses, motor vehicle crashes, and falls, were among the 10 leading causes of death for all age groups in the United States in 2019.* There were 246,041 injury deaths in 2019 (unintentional injury was the most frequent cause of death after heart disease and cancer) with an economic cost of $2.2 trillion (1). Extending a national analysis (1), CDC examined state-level economic costs of fatal injuries based on medical care costs and the value of statistical life assigned to 2019 injury records from the CDC's Web-based Injury Statistics Query and Reporting System (WISQARS).† West Virginia had the highest per capita cost ($11,274) from fatal injury, more than twice that of New York, the state with the lowest cost ($4,538). The five areas with the highest per capita total fatal injury costs were West Virginia, New Mexico, Alaska, District of Columbia (DC), and Louisiana; costs were lowest in New York, California, Minnesota, Nebraska, and Texas. All U.S. states face substantial avoidable costs from injury deaths. Individual persons, families, organizations, communities, and policymakers can use targeted proven strategies to prevent injuries and violence. Resources for best practices for preventing injuries and violence are available online from the CDC's National Center for Injury Prevention and Control.§.

The present study was conducted in Indian states to examine the effect of monetary and non-monetary factors on Infant Mortality Rate (IMR) and Life Expectancy at Birth (LEB) by using the panel regression model. In addition, an attempt was also made to analysis the unequal pattern of health infrastructure and services across states over time with the help of a composite index on health infrastructure and services. It was found that the index value of the best performing state Chhattisgarh is more than fourth six times that of the worst performing state. The study also showed that, despite the higher level of average per capita public health expenditure and moderately better health infrastructure, the COVID 19 induced death rate was high in Punjab, Sikkim, Delhi and Goa. The panel regression results revealed that, an average increase of 1% in the monetary factor, public health expenditure to Gross State Domestic Product ratio (PHEGSDPR), would decrease the average of IMR by about 10%. Moreover, the elasticity of IMR with respect to non-monetary factor, health infrastructure and services per 0.1 million population (HISPLP), was negative and significant. Likewise, the explanatory variables, HISPLP and PHEGSDPR have a positive and significant effect on the LEB.

Objective: In Australia, people residing remotely typically experience increased travel time to health services, and remote health services often have unfavourable population‐to‐provider ratios. The state of Victoria was treated as a case study and a spatial analysis investigated the impact of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) point‐of‐care‐test (POCT) site location (Major City, Inner Regional or Outer Regional) on the mean travel time for closest residents and the number of closest residents. Methods: A network analysis established the travel time from every mesh block in Victoria to the closest POCT site. Inferential analyses investigated the impact of POCT site location on travel time and the number of closest residents. Results: Compared to urban locations, the mean travel time for closest residents to rural POCT sites was significantly higher, while rural POCT sites had significantly fewer residents to service. Conclusions: Findings confirm Australian health service literature suggesting that rural regions have poorer proximate availability of health services, while also contrasting to literature indicating that Australian rural regions have fewer health services per capita. Implications for public health: Localities within outer regional Victoria are candidates for a localised response to reduce unnecessary travel. Employing innovative service models may improve health service access and use and reduce population‐to‐provider ratios in rural locations.

This study uses the China Health and Nutrition Survey data to investigate the relationship between infrastructure construction and health inequality, particularly by exploring a quasi-natural experiment, namely, high-speed rail (HSR) projects. We find that HSR accessibility improves the health of local residents with a coefficient of 0.298, which means that HSR operation will lead to a 2.30% increase in health. HSR accessibility also increases individual income, per capita household income, and the probability of purchasing medical insurance, thereby increasing the health level of individuals. Further analysis shows that HSR reduces the health gap across gender and urban–rural areas. Unfortunately, HSR also increases the health gap among different income groups.

Objectives Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease that may cause physical and functional disability. The objective of this study is to measure prevalence and estimate incremental cost of SLE treatment using information from administrative databases in Colombia. Methods We use data from the patients on the Colombian contributive health system with a period of study from 2015 to 2017. The incremental cost of SLE is estimated using a matched study by propensity score and multivariate balance of covariates. To reduce the effect of possible specification problems, we use Extreme Gradient Boosting, a flexible machine learning algorithm. We use paired t statistical comparison and Bootstrap to validate the robustness of the method. In addition, we use a machine learning regression approach on the cost of control patients to achieve double robustness and compare the results. Results SLE prevalence ranges between 41.65 and 54.47 (cases/100 000), which is lower than other Latin American countries. Using the operative definition of SLE, 5527 patients were selected. The potential control sample was composed of 1 942 253 patients. The total annual direct estimated cost per patient was US $2172. Adjusted incremental cost was US $1662. Considering 4 severity classes of SLE, the cost ranges from US $8823 for severe to US $447 for mild cases. Conclusions Incremental costs of SLE in Colombia are similar to those from other middle-income countries. Compared with high-income countries, the cost is lower; nevertheless, if it is calculated proportional to the per capita health expenditure, it is comparable.

Delivering urological humanitarian aid to countries with greater need has been provided by urologists associated with British Association of Urological Surgeons (BAUS) Urolink over the last 30 years. Urolink has realised the need to understand where that need is geographically, what tangible help is required, and how assistance can be delivered in the most ethically appropriate way. The World Bank stratification of countries by per capita gross national income has helped in the identification of low-come countries or lower-middle-income countries (LMICs), the vast majority of which are in sub-Saharan Africa. The medical and socioeconomic needs of those country's populations, which constitute 17% of the global community, are substantially different from that required in higher income countries. More than 40% of sub-Saharan Africa's population is aged

Tobacco exposure is the major risk factor for lung cancer. Previous studies have shown that there is a correlation between tobacco consumption and lung cancer mortality, but they do not show a specific trend. This study established the polynomial distributed lags (PDLs) model to explore the distributional lag effect between tobacco consumption and lung cancer mortality by using the lung cancer mortality rate of residents in Henan Province and the annual per capita tobacco consumption data from 1992 to 2016 and adopted dynamic simulation prediction method to predict lung cancer mortality for the next 20 years. We found that per capita tobacco consumption had a 10-year lag effect on lung cancer mortality. The harm of tobacco consumption did not show in the first 4 years, but after a lag of 4 years or more, the lung cancer mortality in men was higher than that in women, with a peak effect occurring 10 years later. The prediction showed that if per capita tobacco consumption was controlled, lung cancer mortality would show a steady decline trend after 10 years. These results suggested that tobacco consumption and lung cancer mortality were asynchronous, with a lag effect of tobacco use on the occurrence of lung cancer.

The Chinese government has not only been increasing investments in environmental protection, improving the quality of the ecological environment, but has also been focusing on curbing the excessive growth of medical and healthcare expenses so as to ease the economic burden of China's residents. Both aspects are significant concerns worldwide and have received much research attention individually, but the relationship between government environmental protection expenditure and residents' medical and healthcare expenditure remains unclear. Based on panel data from 31 provinces in China from 2007 to 2019, this paper empirically reveals that fiscal environmental protection expenditure is significantly negatively correlated with per capita medical and healthcare expenditure of residents (including outpatient expenditure and inpatient expenditure). This study shows that increasing the fiscal environmental protection expenditure can help curb the rising level of residents' medical and healthcare expenditure. In addition, the results of heterogeneity analysis indicate that the above relationship is stronger in provinces with a relatively low level of economic development or low proportion of the population over 65 years old. Management implications are discussed.

Objective The aim of this study was to investigate whether increasing costs of delivering care have driven real growth in acute public hospital expenditure in South Australia (SA) and what has contributed to these real cost increases. Methods Using published time-series data, we decomposed inflation-adjusted growth in per capita total acute public hospital recurrent expenditure into its major utilisation and cost components to evaluate their relative contribution over the 12 years to 2017–18. Results Real per capita total acute public hospital recurrent expenditure grew by AU$667 (45.2%) over the 12-year period; of this, 86.0% was from real growth in input costs per weighted activity unit, with real growth in the average salaries of hospital staff accounting for AU$247 or 37.0%. Hospital utilisation rates contributed a minor 14.0%. Conclusion Over the 12 years to 2017–18, real growth in average clinical salaries was a more important driver of real growth in per capita total acute public hospital expenditure than rates of hospital utilisation. This would be facilitated by improvements in the scope, accuracy, quality and consistency of published national hospital data. What is known about the topic? Public hospital expenditure is one of the largest and fastest growing areas of government expenditure in Australia. Policy narratives often centre around demand pressures from an increasingly older, overweight, and chronically ill population. Comparatively little attention has been paid to the influence of increases in real input costs within the Australian context. What does this paper add? Real salary growth has been a major driver of acute public hospital recurrent expenditure growth in SA, whereas hospital utilisation rates have played a minor role. What are the implications for practitioners? A clearer understanding of the main drivers of acute public hospital expenditure growth and the resulting benefits to population health is needed to guide the efficient and sustainable use of scarce healthcare resources.

Background Papua New Guinea (PNG) experienced positive GDP growth at approximately 4.3% per year during the last decade. With increases in overall wealth within the country, PNG is facing a double burden of malnutrition: comparatively high child stunting rates and a growing overweight and obesity epidemic. We focus on the latter by evaluating trends in agri-food import data from 2001 to 2018 and household consumption data from 2018 and 2009/10. Results The analysis presented in this paper raises three red flags. First, international food import data suggest that the demand for ultra-processed, sugar-sweetened beverages and food have increased substantially over time in PNG. Sugar-sweetened beverages dominated the largest growth in processed food imports, increasing by 23% per capita per year between 2001 and 2018. Second, households across the country with a greater food expenditure on sugar-sweetened beverages have a higher probability of an overweight child (under 5 years old). Last, the probability of soft-drink consumption in PNG increases with greater income acquisition and improved market access. While the price of a soft drink is negatively correlated with the quantity consumed, analysis suggests that total household income has a quantitatively larger (and positive) association with soft drink consumption. Conclusions Taxing (or increasing taxes on) sugar-sweetened beverages may not be a sufficient policy mechanism to curb overconsumption of soft drinks in PNG. Education and advocacy programs should be fostered that integrate improved dietary information on packaging, as well as greater access to and understanding of nutrition and diet information of common household consumption items. While increases in household income and market access are crucial to economic growth and transformation, PNG’s economic transition must be dovetailed with programs that expand and enhance health and nutrition information and education to improve household consumption decisions and overall household wellbeing.

Background Multiple survey reports suggest that alcohol use has increased in Canada during the COVID-19 pandemic. However, less is known about how per capita alcohol sales, which predict population-level alcohol use, have changed and whether changes in alcohol sales differ from changes in sales of other products due to pandemic factors. Methods We obtained monthly retail sales data by industry from Statistics Canada, for the six largest provinces in Canada (containing 93% of the national population), between January 2010 and November 2020, representing time before and 9 months after the start of the pandemic in Canada. We used an interrupted time series analysis to estimate pandemic impacts on the dollar value of monthly per capita (per individuals 15+ years) alcohol, essential and non-essential retail sales. We adjusted our analyses for pre-pandemic sales trends, inflation, seasonality and changing population demographics over time. Results During the first 9 months of the pandemic, the values of per capita alcohol, essential and non-essential sales were, respectively, 13.2% higher, 3.6% higher and 13.1% lower than the average values during the same period in the prior 3 years. Interrupted time series models showed significant level change for the value of monthly per capita alcohol sales (+$4.86, 95% CIs: 2.88, 6.83), essential sales (−$59.80, 95% CIs: − 78.47, − 41.03) and non-essential sales (−$308.70, 95% CIs: − $326.60, − 290.79) during the pandemic. Alcohol sales were consistently elevated during the pandemic, and the pre- and post-pandemic slopes were comparable. In contrast, essential and non-essential retail sales declined in the early months of the pandemic before returning to regular spending levels. Conclusion During the first 9 months of the pandemic, per capita alcohol sales were moderately elevated in Canada. In contrast, non-essential sales were lower than prior years, driven by large decreases during the initial months of the pandemic. These findings suggest that the pandemic was associated with increased population-level alcohol consumption, which may lead to increased alcohol-related harms. Ongoing research is needed to examine how factors, including pandemic-related stressors and specific alcohol sales-related policies, may have influenced changes in alcohol use and harms.

The urban and suburban advancement has increased the consumption of energy per capita gradually. Electrical distribution companies have expanded their network to cater to the demand, making the system more vulnerable to low probability high impact events. The extreme events occurred in last five year had shown us complete to partial blackout, which calls for resiliency enhancement. The presented study concentrates on the Dehradun, India, which listed as the most earthquake-prone region by Union Nations Development Programme. Hence, this paper proposes three main strategies to make a resilient distribution grid against an earthquake; (i) Hardening approach at grid side and demand side against earthquake disaster (ii) Monte-Carlo methodology for earthquake hazard model (iii) K-means algorithm with clustering quality index to identify the multiple vulnerable zones. Grid side hardening is performed using the optimal unit placement of the Solar PV plant (SPP) with storage and parallel cables with sectionalizers. For demand-side hardening, electric vehicles are considered storage after an event, duly taking their future growth rate into account. Furthermore, a Mixed Integer non-linear problem is formulated to identify the optimal sizing and sitting of SPP with storage. The proposed methodology is developed and applied to the distribution system (156-bus) of Dehradun, India.

Background The COVID‐19 pandemic has overrun hospital systems while exacerbating economic hardship and food insecurity on a global scale. In an effort to understand how early action to find and control the virus is associated with cumulative outcomes, we explored how country‐level testing capacity affects later COVID‐19 mortality. Methods We used the Our World in Data database to explore testing and mortality records in 27 countries from December 31, 2019, to September 30, 2020; we applied Cox proportional hazards regression to determine the relationship between early COVID‐19 testing capacity (cumulative tests per case) and later COVID‐19 mortality (time to specified mortality thresholds), adjusting for country‐level confounders, including median age, GDP, hospital bed capacity, population density, and nonpharmaceutical interventions. Results Higher early testing implementation, as indicated by more cumulative tests per case when mortality was still low, was associated with a lower risk for higher per capita deaths. A sample finding indicated that a higher cumulative number of tests administered per case at the time of six deaths per million persons was associated with a lower risk of reaching 15 deaths per million persons, after adjustment for all confounders (HR = 0.909; P = 0.0001). Conclusions Countries that developed stronger COVID‐19 testing capacity at early timepoints, as measured by tests administered per case identified, experienced a slower increase of deaths per capita. Thus, this study operationalizes the value of testing and provides empirical evidence that stronger testing capacity at early timepoints is associated with reduced mortality and improved pandemic control.

Focusing on air emissions in South Korean provinces, we investigate whether economic growth has become greener since the implementation of the national green growth strategy in 2009. Given the relevance of regional elements in the economic and environmental policies, the focus lies on spatial aspects. That is, spillovers from nearby provinces are controlled for in a SLX model by means of the Han–Phillips estimator for dynamic panel data. Our results suggest mainly the existence of inverted N-shaped Environmental Kuznets curves for sulfur oxides (SOX) and total suspended particles (TSP). As the curves initially decrease strongly with increasing income, the main cleanup is achieved with the mean income level. However, abatement of the remaining TSP emissions only takes place at higher income levels. While the fixed effects estimations indicate that per capita SOX and TSP emissions have been significantly lower since 2009, the effects vanish once spatial interactions are taken into account and no evidence is found that regional economic growth has become greener. Apart from economic growth, population density and energy consumption are the main drivers of emission changes, with the latter having robust spatial spillovers. The respective spatial interactions decrease with increasing distance and become insignificant after 150 km.

We explore the US states' evolving policy responses to the COVID-19 pandemic by examining governors' decisions to begin easing five types of social distancing policies after the initial case surge in March-April 2020. Applying event history models to original data on state COVID-19 policies, we test the relative influence of health, economic, and political considerations on their decisions. We find no evidence that differences in state economic conditions influenced when governors began easing. Governors of states with larger recent declines in COVID-19 deaths per capita and improving trends in new confirmed cases and test positivity were quicker to ease. However, politics played as powerful a role as epidemiological conditions, driven primarily by governors' party affiliation. Republican governors made the policy U-turn from imposing social distancing measures toward easing those measures a week earlier than Democratic governors, all else equal. Most troubling of all, we find that states with larger Black populations eased their social distancing policies more quickly, despite Black Americans' higher exposure to infection from SARS-CoV-2 and subsequent death from COVID-19. © The Author(s), 2021. Published by Cambridge University Press on behalf of the American Political Science Association.

Objective To examine infertility-related fund-raising campaigns on a popular crowdfunding website and to compare campaign characteristics across states with and without legislative mandates for insurance coverage for infertility-related care. Design Retrospective cohort study. Setting Online crowdfunding platform (GoFundMe) between 2010 and 2020. Patient(s) GoFundMe campaigns in the United States containing the keywords “fertility” and “infertility.” Intervention(s) State insurance mandates for infertility treatment coverage. Main Outcome Measure(s) Primary outcomes included fund-raising goals, funds raised, campaign location, and campaigns per capita. Result(s) Of the 3,332 infertility-related campaigns analyzed, a total goal of $52.6 million was requested, with $22.5 million (42.8%) successfully raised. The average goal was $18,639 (standard deviation [SD] $32,904), and the average amount raised was $6,759 (SD $14,270). States with insurance mandates for infertility coverage had fewer crowdfunding campaigns per capita (0.75 vs. 1.15 campaigns per 100,000 population than states without insurance mandates. Conclusion(s) We found a large number of campaigns requesting financial assistance for costs associated with infertility care, indicating a substantial unmet financial burden. States with insurance mandates had fewer campaigns per capita, suggesting that mandates are effective in mitigating this financial burden. These data can inform future health policy legislation on the state and federal levels to assist with the financial burden of infertility.

Background This population-based study estimated the health-economic costs of dementia from a societal perspective using nationally representative data from 2015 to 2019 and analysed recent trends in Korea. Methods The prevalence of and mortality due to dementia were calculated using the National Health Insurance claims data and population census. The health-economic burden due to dementia was estimated using a prevalence-based approach, including the number of dementia patients and the number of deaths resulting from dementia during 2015–2019. The health-economic burden was presented separately as the national burden and the burden per capita by summing the direct and indirect costs. Results Between 2015 and 2019, the prevalence of dementia among the elderly aged 65 years or older based on clinical diagnosis increased from 5.9 to 7.3%, with approximately 588000 elderly dementia patients in Korea. The total health-economic cost of dementia increased by about 1.5 times in the last 5 years and was estimated to be about USD 4218 million. Direct costs were 52.0% in 2019, and the proportion has been steadily increasing over the past 5 years; indirect costs accounted for 48.0% of the total burden, mainly from family members and caregivers. The health-economic cost per capita due to dementia was approximately USD 6957. Conclusions The burden of dementia in Korea is expected to considerably increase alongside the elderly population in the future. Health policies addressing the prevention and management of dementia should be prioritised.

There are growing concerns about income inequality and health, while little is known about the relationship between income inequality and nutritional outcomes, especially in a transition economy like China. To fill this gap, the aim of this study is to explore the effect of income inequality on the nutritional outcomes of Chinese farmers, including body mass index (BMI), underweight, overweight and obesity statuses. Methodologically this study relies on the theoretical propositions of both income hypothesis and agricultural economics. Specifically, this study compares the literature examining income inequality, then analyses the possible effects of income inequality on the nutritional outcomes of Chinese farmers, and finally tests the results of the analysis using econometric models. Using data from the China Health and Nutrition Survey (CHNS) from 2015, we found that the relationship between income and BMI shifted from positive to negative with rapid growth in per capita household incomes and that higher income inequality can significantly increase the risk of being overweight or obese among low-income groups. In particular, the effect of income inequality on overweight and obesity is higher for males, while its effect tends to be negligible for females. The findings in this study are proved to be robust. Therefore, several policy implications for meeting the challenges concerning income inequality and improving nutritional outcomes for Chinese farmers are also discussed.

Background Oral health is a major public health issue which affects the human life. Access to dental care is one of the important factors in maintaining oral health. This study was aimed to investigate inequality in dental care expenditure in Iranian households. Methods The present study is a secondary analysis of a national cross-sectional survey. The data collected from the Households Income and Expenditure Survey in 2016 and 2017. The final sample consisted of 54,354 households living in rural and urban regions of all the provinces. Inequalities in household’s dental care expenditure per capita in respect to income quintiles and educational level were measured based on the Gini coefficient and concentration index. Results The results showed that about 8% of households had paid for dental care during the month before sampling. The Gini coefficient value was estimated to be 0.97 and 0.96 for dental care expenditure per capita respectively in absolute and relative measure. It indicated a significant inequality in the dental expenditure among the sample households. The values of concentration index were positive and significant for all dental care subcategories in respect to the provincial and national income quintiles as well as the educational level of the head of the household. Conclusions Income and educational inequality in the both absolute and relative dental services expenditure of the Iranian households were in favor of higher income groups as well as higher educational level of household heads. Income inequality was higher in total dental care expenditure per capita and all its subcategories than the educational inequalities of dental expenditure. In order to reduce these inequalities, the policymakers need to pay special attention to low-income households, particularly those with low-educated heads.

Yasinta Rakanita,1,2 Mas Rizky AA Syamsunarno,3 Rano K Sinuraya,1,4 Eka W Suradji,5,6 Rizky Abdulah,1,4 Auliya A Suwantika1,4,7 1Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia; 2College of Pharmaceutical Sciences Pelita Mas, Palu, Indonesia; 3Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; 4Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia; 5Department of Public Health, Faculty of Medicine, Krida Wacana University, Jakarta, Indonesia; 6UKRIDA Hospital, Jakarta, Indonesia; 7Center for Health Technology Assessment, Universitas Padjadjaran, Bandung, IndonesiaCorrespondence: Auliya A SuwantikaDepartment of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, IndonesiaEmail auliya@unpad.ac.idBackground: Up to now, the combinations of ferrous fumarate–folic acid (FF-FA) and ferrous gluconate–multivitamins (FG-MV) have been implemented by the local government in the province of Papua. Nevertheless, there is no a specific economic evaluation that has been applied to investigate the cost-effectiveness of FF-FA and FG-MV.Objective: This study aimed to investigate the cost-effectiveness of FF-FA and FG-MV to be implemented in Teluk Bintuni, as one of the districts with the highest prevalence of iron deficiency anemia in Papua by taking the healthcare perspective into account.Methods: A prospective observational study was applied by considering two groups of women (15– 49 years old) with iron deficiency anemia who received FF-FA and FG-MV from September to November 2018. Applying a purposive sampling method, respondents were selected from 875 targeted women in six sub-districts, who met inclusion criteria. To estimate the total cost, we applied a healthcare perspective that considered direct medical cost only (eg, the procurement cost of iron tablets, cost of Hb test, and cost of healthcare visit). To estimate the effectiveness of intervention, we applied two major parameters, such as Hb level and utility score in quality-adjusted life year (QALY). The cost-effectiveness values were evaluated by using the criteria on the cost-effectiveness of healthcare intervention according to the threshold of gross domestic product (GDP) per capita (cost per QALY gained).Results: From 875 targeted women in six sub-districts who met inclusion criteria, we found approximately 222 women with moderate–severe iron deficiency anemia and 110 women with complete data in the group of FF-FA (n=69) and FG-MV (n-41). The results showed that there were significant differences (p-value < 0.05) on the number of respondents, age, oral iron cost, total healthcare cost and utility score in both intervention groups. Comparing the use of FG-MV with FF-FA, we estimated the incremental cost-effectiveness ratios (ICERs) would be $255.77 per controlled patient, $142.09 per patient with Hb increment > 2.00 g/dL, $79.93 per patient with Hb increment > 1.00 g/dL, and $11.59 per QALY gained.Conclusion: The ICER was estimated to be $11.59 per QALY gained, which was highly cost-effective, according to GDP-based cost-effectiveness threshold. In addition, the utility score of women with iron deficiency anemia was considered to be the most influential factor impacting the cost-effectiveness value.Keywords: ICER, cost per controlled patient, cost per patient with Hb increment > 2.00 g/dL, cost per patient with Hb increment > 1.00 g/dL, cost per QALY gained

Iceland is an island nation located in the North Atlantic with a population of approximately 364,000 people and a total area of 103,000 km2 (1). It is one of the most sparsely populated countries in Europe, which can pose challenges in health care provision. Two-thirds of the population live within the capital area of Reykjavik, whereas the remainder is dispersed widely along the coastline, as central areas of the country are largely uninhabitable. Life expectancy in Iceland is high: 81.0 years for men and 84.2 for women (2). Iceland has a universal health care system, which covers anyone who has been a legal resident for >6 months. Over 80% of health care costs are covered by the state and funded through taxes (3). In 2019, per capita gross domestic product was 66,945 United States dollars (USD), and in that year, government spending on health care amounted to 7.4% of Iceland’s gross domestic product (4,5). Copays for primary care clinic visits, dental services, and medications account for the majority of out-of-pocket costs. Annual out-of-pocket expenses per individual are currently capped at 613 USD for medical care and at 488 USD for prescription medications, with lower thresholds set for senior citizens. The number of practicing physicians per 1000 inhabitants in Iceland is 3.9, slightly above the mean in European Union countries of 3.6/1000 inhabitants (3,6). The number of adult nephrologists per 1,000,000 inhabitants is 2.75. To stay up to date, avoid isolation of small groups of Icelandic physicians, and ensure an adequately broad case mix and sufficient patient volume during training, postgraduate education must be obtained abroad in most medical specialties. Icelandic nephrologists currently in practice have received their training in The Netherlands, Sweden, and the United States. All hospitals in Iceland are run by a nonprofit …

The sustainable development goal #2 aims at ending hunger and malnutrition by 2030. Given the numbers of food insecure and malnourished people on the rise, the heterogeneity of nutritional statuses and needs, and the even worse context of COVID-19 pandemic, this has become an urgent challenge for food-related policies. This paper provides a comprehensive microsimulation approach to evaluate economic policies on food access, sufficiency (energy) and adequacy (protein, fat, carbohydrate) at household level. The improvement in market access conditions in Kenya is simulated as an application case of this method, using original insights from households’ surveys and biochemical and nutritional information by food item. Simulation’s results suggest that improving market access increases food purchasing power overall the country, with a pro-poor impact in rural areas. The daily energy consumption per capita and macronutrients intakes per capita increase at the national level, being the households with at least one stunted child under 5 years old, and poor households living areas outside Mombasa and Nairobi, those which benefit the most. The developed method and its Kenya's application contribute to the discussion on how to evaluate nutrition-sensitive policies, and how to cover most households suffering food insecurity and nutrition deficiencies in any given country. Fil: Ramos, Maria Priscila. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Saavedra 15. Instituto Interdisciplinario de Economía Política de Buenos Aires. Universidad de Buenos Aires. Facultad de Ciencias Económicas. Instituto Interdisciplinario de Economía Política de Buenos Aires; Argentina Fil: Custodio, Estefanía. Instituto de Salud Carlos Iii (isciii); España Fil: Jiménez, Sofía. Universidad de Zaragoza; España Fil: Mainar Causapé, Alfredo J.. Universidad de Sevilla; España Fil: Boulanger, Pierre. No especifíca; Fil: Ferrari, Emanuele. No especifíca

Lack of rapidly available neurological expertise, especially in rural areas, is one of the key obstacles in stroke care. Stroke care networks attempt to address this challenge by connecting hospitals with specialized stroke centers, stroke units, and hospitals of lower levels of care. While the benefits of stroke care networks are well-documented, travel distances are likely to increase when patients are transferred almost exclusively between members of the same network. This is particularly important for patients who require mechanical thrombectomy, an increasingly employed treatment method that requires equipment and expertise available in specialized stroke centers. This study aims to analyze the performance of the current design of stroke care networks in Bavaria, Germany, and to evaluate the improvement potential when the networks are redesigned to minimize travel distances. To this end, we define three fundamental criteria for assessing network design performance: 1) average travel distances, 2) the populace in the catchment area relative to the number of stroke units, and 3) the ratio of stroke units to lower-care hospitals. We generate several alternative stroke network designs using an analytical approach based on mathematical programming and clustering. Finally, we evaluate the performance of the existing networks in Bavaria via simulation. The results show that the current network design could be significantly improved concerning the average travel distances. Moreover, the existing networks are unnecessarily imbalanced when it comes to their number of stroke units per capita and the ratio of stroke units to lower-care hospitals.

Many studies have evaluated factors that influence the course of the COVID-19 pandemic in different countries. This multicountry study assessed the influence of democracy and other factors on the case fatality rate of COVID-19 during the early stage of the pandemic. We accessed the World Health Organization, World Bank, and the Democracy Index 2019 databases for data from the 148 countries. Multiple analyses were conducted to examine the association between the Democracy Index and case fatality rate of COVID-19. Within 148 countries, the percentage of the population aged 65 years and above (p = 0.0193), and health expenditure as a percentage of GDP (p = 0.0237) were positively associated with countries’ case fatality rates. By contrast, hospital beds per capita helped to reduce the case fatality rates. In particular, the Democracy Index was positively associated with case fatality rates in a subgroup of 47 high-income countries. This study suggests that enhancing the health system with increased hospital beds and healthcare workforce per capita should reduce case fatality rate. The findings suggest that a higher Democracy Index is associated with more deaths from COVID-19 at the early stage of the pandemic, possibly due to the decreased ability of the government.

Background Despite widespread use of long-lasting insecticidal nets (LLINs) and other tools, malaria caused 409,000 deaths worldwide in 2019. While indoor residual spraying (IRS) is an effective supplement, IRS is moderately expensive and logistically challenging. In endemic areas, IRS requires yearly application just before the main rainy season and potential interim reapplications. A new technology, insecticide-treated wall liner (ITWL), might overcome these challenges. Methods We conducted a 44-cluster two-arm randomized controlled trial in Muheza, Tanzania from 2015 to 2016 to evaluate the cost and efficacy of a non-pyrethroid ITWL to supplement LLINs, analyzing operational changes over three installation phases. The estimated efficacy (with 95% confidence intervals) of IRS as a supplement to LLINs came mainly from a published randomized trial in Muleba, Tanzania. We obtained financial costs of IRS from published reports and conducted a household survey of a similar IRS program near Muleba to determine household costs. The costs of ITWL were amortized over its 4-year expected lifetime and converted to 2019 US dollars using Tanzania’s GDP deflator and market exchange rates. Results Operational improvements from phases 1 to 3 raised ITWL coverage from 35.1 to 67.1% of initially targeted households while reducing economic cost from $34.18 to $30.56 per person covered. However, 90 days after installing ITWL in 5666 households, the randomized trial was terminated prematurely because cone bioassay tests showed that ITWL no longer killed mosquitoes and therefore could not prevent malaria. The ITWL cost $10.11 per person per year compared to $5.69 for IRS. With an efficacy of 57% (3–81%), IRS averted 1162 (61–1651) disability-adjusted life years (DALYs) per 100,000 population yearly. Its incremental cost-effectiveness ratio (ICER) per DALY averted was $490 (45% of Tanzania’s per capita gross national income). Conclusions These findings provide design specifications for future ITWL development and implementation. It would need to be efficacious and more effective and/or less costly than IRS, so more persons could be protected with a given budget. The durability of a previous ITWL, progress in non-pyrethroid tools, economies of scale and competition (as occurred with LLINs), strengthened community engagement, and more efficient installation and management procedures all offer promise of achieving these goals. Therefore, ITWLs merit ongoing study. First posted 2015 (NCT02533336).

The elderly account for the majority of medical spending in many countries, raising concerns about potentially unnecessary spending, especially during the final months of life. Using a well-defined starting point (hospitalization for an initial acute myocardial infarction) with evidence-based postevent treatments, we examined age trends in treatments in the US and Norway, two countries with high levels of per capita medical spending. After accounting for comorbidities, we found marked decreases within both countries in the use of invasive treatments with age (for example, less use of percutaneous coronary interventions and surgery) and the use of relatively inexpensive medications (for example, less use of anticholesterol [statin] drugs for which generic versions are widely available). The treatment decreases with age were larger in Norway compared with those in the US. The less frequent treatment of the oldest of the old, without even use of basic medications, suggests potential age-related bias and a disconnect with the evidence on treatment value. Hospital organization and payment in both countries should incentivize greater equity in treatment use across ages.

We investigate the impact of healthcare resource availability on opioid prescribing rates. Utilizing healthcare provider shortage area (HPSA) scores, we show that fewer healthcare resources have higher opioid prescribing rates. However, more doctors per capita are associated with significantly higher opioid prescribing rates. This suggests that patients “doctor shop”, finding providers willing to prescribe opioids. It also suggests that part of the rural opioid epidemic is a function of healthcare resource availability. It implies that policies that incentivize care provided by non-prescribing healthcare workers, such as nurses, may alleviate some opioid issues in impoverished areas.

This study analyzes how climate change affects the economy, society, and environment in South Korea. Then, the study explores the ways to strengthen capabilities that can alleviate climate change impacts. To find them, the study employs a system dynamics simulation method and builds a model with several sectors including the urban, rural, population, and social-environmental sectors. The study compares the size of climate change damages in rural and urban areas. The results with representative concentration path (RCP) 8.5 show that the size of climate change damage will continue to increase by 2050. The projected damages from the reduced industrial outputs in urban areas will be larger than that in rural areas. The results also show that the service sector will face stronger impacts from climate change than the manufacturing and agricultural sectors. However, the total size of damage in the rural areas will be bigger than that of the urban areas. It is because the size of reduced industrial outputs per capita in the rural areas is twice bigger than that of the urban areas. The climate change damage in the social and environmental sectors (including a loss of biodiversity and an increase in health costs) account for the largest part of the total damage. The study finally provides suggestions and policies that can improve the capabilities to reduce the climate change damages. One of the major suggestions of this study is that the increase in the climate change budget corresponding to the GDP growth can minimize the size of climate change impacts.

Assessing the cost of vaccine preventable diseases (VPD) surveillance is becoming more important in the context of the Global Polio Eradication Initiative (GPEI) funding transition, since GPEI support to polio surveillance helped the incremental building of VPD surveillance systems in many countries, including low income countries such as Nepal. However, there is limited knowledge on the cost of conducting VPD surveillance, especially the national cost for surveillance of multiple vaccine-preventable diseases. The current study sought to calculate the economic and financial costs of Nepal’s comprehensive VPD surveillance systems from July 2016 to July 2017. At thecentral level, all surveillance units were included in the sample. At sub-national level, a purposive sampling strategy was used to select a representative sample from locations involved in conducting surveillance. The sub-national sample costs were extrapolated to the nationwide VPD surveillance system. Nepal’s total annual economic cost of VPD surveillance was USD 4.81 million or USD 0.18 per capita, while the total financial cost was USD 4.38 million or USD 0.16 per capita. Government expenditures accounted for 56% of the total economic cost, and World Health Organization accounting for 44%. The biggest cost driver was personnel accounting for 51% of the total economic cost. WHO supported trained surveillance personnel through donor funding, mainly from Global Polio Eradication Initiative. As a polio transition priority country, Nepal will need to make strategic choices to fully self-finance or seek full donor support or a mixed-financing model as polio program funding diminishes.

We provide a three-step analysis of the effects and responses to COVID-19 in Nordic countries (Denmark, Finland, Norway and Sweden), large Western European countries (France, Germany, Italy, Spain and United Kingdom) and OECD Europe. First, we compare public health trends over 2020 in terms of per capita COVID-19 cases, fatalities, testing and the stringency of social distancing (SD) measures. Second, in a ‘like-with-like’ policy response model between Nordic countries, we test for the effects of air border closures on the growth in per capita COVID-19 cases while accounting for differences in stringency of social distancing and other measures. Third, using data from OECD European countries, we regress percentage change in GDP (2020–2019) on cumulative per capita national COVID-19 fatalities. We find that: (1) Sweden is an outlier, relative to its Nordic neighbours, in its COVID-19 public health outcomes; (2) Sweden would have had reduced cases and fatalities if it had adopted the air border closures implemented by its Nordic neighbours in the first half of 2020; and, (3) for OECD Europe, there is a statistically significant and negative association between per capita COVID-19 fatalities and economic performance.

There is an opportunity to determine how best to deploy sexually transmitted infection testing technologies to improve health. Our results suggest that a mixed (hub-and-spoke) approach offered the lowest cost per adverse outcome averted. Supplemental digital content is available in the text., Background Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections (STIs) associated with adverse outcomes, yet most countries do not test and conduct syndromic management, which lacks sensitivity and specificity. Innovations allow for expanded STI testing; however, cost is a barrier. Methods Using inputs from a pilot program in Botswana, we developed a model among a hypothetical population of 50,000 pregnant women to compare 1-year costs and outcomes associated with 3 antenatal STI testing strategies: (1) point-of-care, (2) centralized laboratory, and (3) a mixed approach (point of care at high-volume sites, and hubs elsewhere), and syndromic management. Results Syndromic management had the lowest delivery cost but was associated with the most infections at delivery, uninfected women treated, CT/NG-related low-birth-weight infants, disability-adjusted life years, and low birth weight hospitalization costs. Point-of-care CT/NG testing would treat and cure the most infections but had the highest delivery cost. Among the testing scenarios, the mixed scenario had the most favorable cost per woman treated and cured ($534/cure). Compared with syndromic management, the mixed approach resulted in a mean incremental cost-effectiveness ratio of $953 per disability-adjusted life years averted, which is cost-effective under World Health Organization's one-time per-capita gross domestic product willingness-to-pay threshold. Conclusions As countries consider new technologies to strengthen health services, there is an opportunity to determine how to best deploy resources. Compared with point-of-care, centralized laboratory, and syndromic management, the mixed approach offered the lowest cost per infection averted and is cost-effective if policy makers' willingness to pay is informed by the World Health Organization's gross domestic product/capita threshold.

Introduction The survival of patients with relapsed small cell lung cancer (SCLC) has achieved little progress in the last several decades. ALTER1202 confirmed the efficacy and safety of anlotinib as a third- or further-line option for relapsed SCLC. This study aimed to assess the cost-effectiveness of anlotinib compared with placebo as third- or further-line treatment for advanced SCLC in China. Methods A Markov model was developed to simulate the process of advanced SCLC and estimate the incremental cost-effectiveness ratio (ICER) of anlotinib versus placebo. The health outcomes and utilities were derived from the ALTER1202 (NCT03059797) and published sources, respectively. Total costs were calculated from the perspective of Chinese society. One-way and probabilistic sensitivity analyses (PSA) were conducted to explore the model uncertainties. Results Anlotinib was estimated to result in an additional 0.12 quality-adjusted life-years (QALYs) at an incremental cost of $2131.32, resulting in an ICER of $17,741.94/QALY. The ICER did not exceed the willingness-to-pay (WTP) threshold of $30,833 per QALY, which was three times the gross domestic product (GDP) per capita of China in 2019. One-way sensitivity analysis showed that the cost of anlotinib exerted the maximum influence on the result of the model, followed by the utility of progression-free survival (PFS) state in the anlotinib group and median overall survival (mOS) in the anlotinib group. In PSA, the probability of anlotinib being cost-effective was 26.6% and 78.5% when the WTP threshold was one and three times the GDP per capita, respectively. Conclusion Anlotinib is likely to be a cost-effective option compared with placebo for patients with relapsed SCLC who experience failure of at least two lines of chemotherapy in China. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01889-2.

Substandard housing is considered a public health issue worldwide. Migrants are more likely than other individuals to experience poor housing conditions in urban China, and these challenges in housing conditions have deep effects on migrant health. This study characterizes the relationship between housing satisfaction and migrant health in Hangzhou, China. In particular, 17 indicators for assessing housing satisfaction, which include the indoor environment (IE), outdoor environment (OE) and safety (SE), are integrated. In order to reveal the physical health and mental health status of migrants, a physical component summary (PCS) and mental component summary (MCS) were assessed by using a Twelve-Item Short-Form Health Survey. Multivariate linear regression was further employed to quantify the associations between housing satisfaction and migrant health. The results showed that high satisfaction with the indoor environment, outdoor environment and safety can improve the physical health of migrants. High housing satisfaction, in addition to satisfaction with the outdoor environment, has a significant relationship with the mental health of migrants. Income is associated with migrant health since it plays a key role in determining migrants’ socioeconomic and demographic characteristics and subjective aspirations. However, per capita living space does not have a significant association with migrant health because most of the migrants live in small living spaces in the study area. According to the findings, implications for housing policies that can better integrate housing conditions and health are proposed.

Objective To evaluate the cost-effectiveness of the implementation of national lung cancer (LC) screening programme (SP) in a high-risk population from the perspective of the Spanish National Health System (NHS). Methods A cost-effectiveness analysis for a LC SP was carried out on a lifetime horizon. A Markov model was designed that assumed two scenarios, one with the implementation of the SP and another one without it. Effectiveness and cost of LC management, diagnosis and screening were included in the different health states. Deterministic and probabilistic sensitivity analyses were conducted to evaluate its robustness. A discount rate was set at 3% both for effectiveness and cost. Results In the base-case, an increase of 4.80 quality-adjusted life years (QALY) per patient was obtained, resulting in an incremental cost-effectiveness ratio of €2345/QALY. Probabilistic sensitivity analysis showed the national LC SP to be cost-effective in 80% of cases (probability=0.8) for a willingness-to-pay threshold equivalent to the gross domestic product per capita in Spain, which was set at €25 854/QALY in 2018 based on the per capita income of Spain. The sensitivity analysis indicates that the obtained results are robust in terms of changes in the presentation rates and costs, and the cost-effectiveness thresholds. Conclusions This analysis suggests that the implementation of a LC SP in the high-risk Spanish population would be a cost-effective strategy for the Spanish NHS.

This study aimed to assess the association between the trend of urban-rural disparity in high blood pressure (HBP) in Chinese children and adolescents and socioeconomic development. Data on 1,054,602 students aged 7-18 years were obtained from five successive national surveys administered in 29 Chinese provinces in 1995, 2000, 2005, 2010, and 2014. HBP was defined as average measured systolic BP and/or diastolic BP equal to or more than 95th percentile. The socioeconomic indicators at the provincial-level included gross domestic product (GDP) per capita, the Engel coefficient, and urbanization rates. From 1995 to 2014, HBP prevalence in Chinese children and adolescents fluctuated between 6.9% and 9.2%. Rural areas had a higher prevalence of HBP than urban areas, with a diminishing trend in urban-rural disparity from 1995 to 2010 with a reduced OR from 1.45 (95% CI: 1.40-150) in 1995 to 1.09 (1.05-1.12) in 2010, whereas a widening gap in 2014 with OR of 1.23 (1.19-1.26)). A positive association existed between the improvement of socioeconomic indicators and the increase in HBP, which was demonstrated obviously by the Engel coefficient strata. The increases in the urbanization rates were accompanied by a greater increase of HBP in urban than in rural areas. The large urban-rural disparity suggests a priority of HBP control in rural children due to their current and future HBP and cardiovascular disease risks. Socioeconomic development could affect the urban-rural disparity in HBP risk, reflecting the importance of effective policy responses for preventing HBP by avoiding unhealthy lifestyles brought about by rapid economic development.

Background Climate change presents an increasing challenge for food-nutrition security. Nutrition metrics calculated from quantitative food system projections can help focus policy actions. Objectives To estimate future chronic and hidden hunger disability-adjusted life years (DALYs)—due to protein-energy undernutrition and micronutrient deficiencies, respectively—using food systems projections to evaluate the potential impact of climate change and agricultural sector investment for adaptation. Methods We use a novel combination of a chronic and hidden hunger DALY estimation procedure and food system projections from quantitative foresight modeling to assess DALYs under alternative agricultural sector scenarios to midcentury. Results Total chronic and hidden hunger DALYs are projected to increase globally out to 2050—by over 30 million compared with 2010—even without climate change. Climate change increases total DALY change between 2010 and 2050 by nearly 10% compared with no climate change. Agricultural sector investments show promise for offsetting these impacts. With investments, DALY incidence due to chronic and hidden hunger is projected to decrease globally in 2050 by 0.24 and 0.56 per 1000 capita, respectively. Total global DALYs will still rise because projected population growth will outpace the rate reduction, especially in Africa south of the Sahara. However, projections also show important regional reductions in total DALYs due to chronic (13.9 million in South Asia, 4.3 million in East Asia and the Pacific) and hidden hunger (7.5 million in East Asia and the Pacific) with investments. Conclusions Food system projections to 2050 show a decreasing DALY incidence from both chronic and hidden hunger. Population growth is projected to outpace these improvements and lead to increasing total chronic and hidden hunger DALYs globally, concentrated in Africa south of the Sahara. Climate change increases per-capita chronic and hidden hunger DALY incidence compared with no climate change. Agricultural sector investments show the potential to offset the climate impact on DALYs.

Objectives Increased life expectancy results in greater challenges posed to healthcare. Concurrently, a shortage of healthcare workforce, including nurses, has been observed. Thus, an urgent need exists to implement improvements in healthcare services based on sufficient evidence. The aim of the study was to evaluate the influence of the relative number of nurses/midwives on life expectancy, and the influence of selected economic variables: gross domestic product (GDP), health expenditure as a percentage of GDP, and health expenditure per capita , on this number. The aim of the study was to evaluate the influence of the relative number of nurses/midwives on life expectancy, and the influence of select economic variables: GDP, health expenditure as a percentage of GDP, and health expenditure per capita on this number. Material and Methods A retrospective analysis based on data from 46 countries was performed. Correlations between the relative number of nurses/midwives and life expectancy as well as economic variables were evaluated. To trace the differences between the countries with different relative numbers of nurses/ midwives, the countries were divided into groups as follows – group 1: 10 nurses and midwives/1000 inhabitants. Results Correlations were found between the relative number of nurses/midwives and life expectancy (p < 0.001, r = 0.68), and economic variables (p < 0.001, r = 0.82; p < 0.001, r = 0.62, and p < 0.001, r = 0.8, respectively). Life expectancy was higher in group 3 vs. groups 1 and 2 (p < 0.001 and p = 0.036, respectively), and in group 2 vs. group 1 (p = 0.006). Economic variables were higher in group 3 vs. group 1 (p < 0.001 for all) and group 2 (p = 0.016, p = 0.025, p = 0.022, respectively), and in group 2 vs. group 1 (p = 002, p = 0.024, p = 0.002, respectively). Conclusions The relative number of nurses/midwives correlates with life expectancy and relies on the country’s income and level of healthcare system financing. Int J Occup Med Environ Health. 2021;34(4):505–12

Health events emerge from host, community, environment, and pathogen factors—forecasting epidemics is a complex task. We describe an exploratory analysis to identify economic risk factors that could aid epidemic risk assessment. A line list was constructed using the World Health Organization Disease Outbreak News (2016–2018) and economic indicators from the World Bank. Poisson regression employing forward imputations was used to establish relationships with the frequency with which countries reported public health events. Economic indicators demonstrated strong performance appropriate for further assessment in surveillance programming. In our analysis, three economic indicators were significantly associated to event reporting: how much the country’s urban population changed, its average forest area, and a novel economic indicator we developed that assessed how much the gross domestic product changed per capita. Other economic indicators performed less well: changes in total, female, urban, and rural population sizes; population density; net migration; change in per cent forest area; total forest area; and another novel indicator, change in percent of trade as a fraction of the total economy. We then undertook a further analysis of the start of the current COVID-19 pandemic that revealed similar associations, but confounding by global disease burden is likely. Continued development of forecasting approaches capturing information relevant to whole-of-society factors (e.g., economic factors as assessed in our study) could improve the risk management process through earlier hazard identification and inform strategic decision processes in multisectoral strategies to preventing, detecting, and responding to pandemic-threat events.

BackgroundGlobally,Haemophilus influenzaetype b (Hib) vaccine has substantially reduced the burden of Hib invasive disease. However, China remains the only country not to include Hib vaccine into its national immunization program (NIP), although it accounts for 11% of global Hib deaths. We aimed to assess the cost-effectiveness of including Hib vaccine in China’s NIP at the national and provincial levels.MethodsUsing a decision-tree Markov state transition model, we estimated the cost-effectiveness of Hib vaccine in the NIP compared to thestatus quoof Hib vaccine in the private market for the 2017 birth cohort. Treatment costs and vaccine program costs were calculated from Chinese Center for Disease Control and Prevention (CDC) and national insurance databases. Epidemiological data and other model parameters were obtained from published literature. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICER) were predicted by province. Deterministic and probabilistic sensitivity analyses were performed to explore model uncertainty.ResultsIncluding Hib vaccine in the NIP was projected to prevent approximately 2700 deaths (93% reduction) and 235,700 cases of Hib disease (92% reduction) for the 2017 birth cohort at the national level. Hib vaccine was cost-effective nationally (US$ 8001 per QALY gained) compared to the GDP per capita and cost-effective in 15 of 31 provinces. One-way and scenario sensitivity analyses indicated results were robust when varying model parameters, and in probabilistic sensitivity analysis, Hib vaccine had a 64% probability of being cost-effective nationally.ConclusionIntroducing Hib vaccine in China’s NIP is cost-effective nationally and in many provinces. Less socioeconomically developed provinces with high Hib disease burden and low access to Hib vaccine in the current private market, such as those in the west region, would benefit the most from adding Hib vaccine to the NIP. In the absence of a national policy decision on Hib vaccine, this analysis provides evidence for provincial governments to include Hib vaccine into local immunization programs to substantially reduce disease burden and treatment costs.

Background: Adjuvant chemotherapy with trastuzumab for HER2 positive breast cancers has brought considerable benefits to disease-free survival and overall survival.Objective: To conduct a cost-effectiveness analysis of the treatment of patients with early and locally advanced HER2 positive breast cancer, within the scope of the Brazilian public health system, comparing adjuvant chemotherapy with and without trastuzumab, for 1 year of treatment.Methods: A 4-state Markov model was developed to estimate strategy costs and outcomes.Results: Based on the proposed model, we verified an incremental benefit of trastuzumab therapy compared to treatment without trastuzumab with 0.84 quality-adjusted life years (QALY) and 1.16 life years gained (LYG). The use of adjuvant chemotherapy with trastuzumab has an ICER of US$19,599.26 for each quality-adjusted life year and US$14,180.68 for each life year gained in relation to chemotherapy without trastuzumab.Conclusion: In Brazil, adjuvant chemotherapy with trastuzumab may be considered cost-effective only if a cost-effectiveness threshold is stipulated with the value starting at three times the Brazilian GDP per capita for QALY or two times the Brazilian GDP per capita for LYG, from health system perspective.

Background The Syrian conflict has produced one of the largest refugee crises in modern times. Lebanon has taken in more Syrian refugees per capita than any other nation. We aimed to study the burden of surgical disease and access to surgical care among Syrian refugees in Lebanon. Methods This study was designed as a convenient cross-sectional cluster-based population survey of all refugee camps throughout the Bekaa region of Lebanon. We used a modified version of the Surgeons OverSeas Assessment of Surgical Need to identify surgical conditions and barriers to care access. The head of household of each informal tented settlement provided demographic information after which two household members were randomly chosen and administered the survey. Results A total of 1,500 individuals from 750 households representing 21 camps were surveyed. Respondents had a mean age of 36.6 (15.0) years, 54.6% were female, and 59% were illiterate. Nearly 25% of respondents reported at least one surgical condition within the past year, most commonly involving the face, head, and neck region (32%) and extremities (22%). Less than 20% of patients with a surgical condition reported seeing any healthcare provider, > 75% due to financial hardship. Conclusions The prevalence of surgical disease among Syrian refugees is very high with a fourth of refugees suffering from one or more surgical conditions over the past year. The surgical needs of this vulnerable population are largely unmet as financial reasons prevent patients from seeking care. Local and humanitarian efforts need to include increased access to surgical care.

Using two-wave balanced panel data from the China Health and Retirement Longitudinal Survey (CHARLS), this study examines the association between the number of children and the monetary transfers received by elderly parents in rural China. Through theoretical and empirical analysis, we find evidence that parents with more children receive more economic transfers. For each additional child, the probability of receiving transfers increases by 3.1%, and the amount of total transfers increases by 328 yuan, which is roughly equivalent to 5 percentage points of the per capita pre-transfer income of rural families. We conclude that the positive impact for the elderly is mainly reflected in cash transfers, specifically for those from high-income families, with non-co-residence with their children, and aged 60–69. Meanwhile, the quality of offspring and intimate parent–child ties stimulate the effectiveness of the number of children on the monetary transfers received by elderly persons. From the younger generation’s perspective, more siblings also contribute to reducing the burden of support for each child. These findings enhance our understanding of the relationship between the number of children and upstream intergenerational monetary transfers, and provide us with a useful reference for future policy design that encourages children to meet their filial obligations.

Different countries were successful in different ways in their attempts to contain the spread of the coronavirus, which compromised the health of many people. Stress levels rose and the restrictive measures impacted the citizens' trust in institutions. An important resource for managing crises is a country’s economic growth. Given that the gross domestic product (GDP) per capita is one indicator of economic growth, the goal of this study is to investigate the differences in perceived stress and trust in institutions between European countries categorized into below-average, average and above-average GDP per capita levels during the coronavirus pandemic. The analyses of N = 84,080 participants from 29 countries gathered via an online survey showed that citizens of higher-level GDP per capita countries experienced less stress and had more trust in institutions. Compared to the average level, Croatian citizens experienced somewhat higher stress and had somewhat higher trust in the government’s measures. These results imply that economic growth is one of the country-level factors associated with the quality of managing the coronavirus pandemic.

Objective Assess the impact of the Be Your Own Baby (BYOB) public awareness campaign including population-level exposure, the effectiveness of ad platforms, and the effect of the campaign on family planning clinic attendance, the campaign's primary goal. Data sources The study relied on administrative data on traffic and engagement from the campaign's website, population survey data measuring campaign exposure, and clinic attendance volumes from state-by-year restricted-use versions of the Office of Population Affairs' Family Planning Annual Reports (2006-2018). Study design Bivariate analyses were used to assess website traffic and engagement and population-level exposure across key subgroups. We then used the synthetic control method to examine the impact of the BYOB campaign on per capita Title X clinic attendance among the target demographic, women 18-29 years of age. Data collection/extraction methods Not applicable. We relied on secondary sources. Principal findings Primary media platforms used by the campaign included social media, digital display, streaming audio, YouTube, and search. Website traffic was driven primarily by digital display ads, but engagement was highest for search. Our results suggest nearly 12% of Delaware women 18-29 years of age were exposed to the campaign. However, exposure was measured at the end of the campaign and was likely much larger during its peak. Our results indicated that the campaign was associated with between 13 and 23 additional Title X clinic visits per 1000 women compared with 110 users per 1000 at baseline in 2014. Conclusions Our findings suggest the BYOB campaign was successful at increasing clinic attendance among the target demographic. These results have important implications for other programs seeking to use public awareness messaging to increase participation in the health care system and are especially important for Title X administrators who have faced declining patient volumes for over 10 years.

The COVID-19 has been a worldwide pandemic and it needs for studies related to effect on people's demand for insurance during the pandemic which is an important way to transfer risk. However, there is a lack of research linking COVID-19 and people's demand for insurance. The objective of this paper is to investigate the impact of COVID-19 pandemic on issuance demand, using data covering 241 cities on confirmed COVID-19 cases and insurance company revenue in China. The empirical results show that more confirmed COVID-19 cases are associated with greater per capita insurance revenue and the results are robust when considering endogeneity concern. Economically, the per capita insurance revenue increases by 0.896 Yuan for each more confirmed case. In terms of insurance type, the greatest increased insurance revenue is for life insurance, followed by health insurance. We further consider the heterogeneity of regions and find that the impact of COVID-19 on insurance revenue only exists in regions with worse medical treatment conditions or higher medical burden.