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Purpose: The purpose of this article is to provide a critical account of the hate crime (HC) paradigm by exploring its historical legal definition and the limitations in addressing the multiple and structural discriminations faced by minority groups. Specifically, the article focuses on the case of Italy, where in recent years a fierce debate over a proposed law on HC against LGBT+ and disabled people ended in its rejection due to neoconservative and Catholic opposition. Design/methodology/approach: Drawing on critical socio-criminological literature on HC, the paper analyses the Italian debates and socio-legal context over the past two decades regarding discrimination against LGBT+ groups and its (lack of) criminalization. It also provides a secondary analysis of recent data on violence and discrimination against LGBT+ people, collected by the Fundamental Rights Agency (FRA). Findings: The analysis of the debate and the data collected shows that the criminal definition of HC is insufficient to capture the wider range of social and cultural violence and discrimination against LGBT+ people. Indeed, data analysis shows the effect of the low level of recognition of rights on the propensity of people to denounce and of social practitioners to recognize, discrimination and violence against LGBT+ people. It is therefore argued that the discussion on HC should move beyond the criminalization of individual violence to be entrenched in a broader reflection over the lack of recognition of sexual citizenship rights which perpetuates the vulnerability of LGBT+ people. Originality/value: This paper contributes to the international socio-criminological debate on HC. It argues for a comprehensive framework that recognizes the structural nature of discrimination and violence against vulnerable groups by framing discrimination and violence against LGBT+ people as a citizenship right rather than a criminal justice issue. [ABSTRACT FROM AUTHOR]

A panel of 24 international experts met in July 2022 to discuss challenges associated with pertussis detection, monitoring, and vaccination in adults; conclusions from this meeting are presented. There has been a shift in the epidemiology of pertussis toward older children and adults. This shift has been attributed to the waning of infection- or vaccine-induced immunity, newer detection techniques causing detection bias, and possibly the replacement of whole-cell pertussis with acellular vaccines in high-income countries, which may lead to immunity waning more quickly. The burden of adult pertussis is still likely under-ascertained due to widespread under-recognition by healthcare professionals (HCPs), under-diagnosis, and under-reporting in this age group. Non-standardized testing guidance and varied case definitions have contributed to under-reporting. Key barriers to HCP engagement with the tetanus, diphtheria, and pertussis (Tdap) vaccine include low awareness, lack of time/funding, and lack of motivation due to low prioritization of Tdap.

Data on retrospective compensation claims for injuries caused by pharmaceutical drugs are prone to selection and reporting biases. Nevertheless, this case study of the antidiabetic drug benfluorex shows that such data can be used to estimate the cumulative incidence of drug‐related injury, and to provide insights into its epidemiology. To this end, we develop a modelling framework for under‐reporting of retrospective claims for compensation arising from drug damage. The model involves a longitudinal component related to attrition of cases over time, and a cross‐sectional component related to incomplete reporting. We apply this model to cardiac valve surgery necessitated by exposure to benfluorex. Benfluorex was marketed in France between 1976 and 2009, when it was withdrawn because it caused valvular heart disease. A scandal erupted in 2010 over the scale of the damage caused by the drug. Since then, no further estimates of cumulative incidence have been published, though thousands of claims for compensation have been processed. The analysis combines compensation claims data and sociological survey data on benfluorex users, together with data on benfluorex sales and duration of treatment. We find a threshold of toxicity at about 6 months' exposure, and that at least 1690 individuals (95% CI 1290 to 2320) needed heart surgery to replace or repair valves damaged by exposure to benfluorex in France: a cumulative incidence of 3.68 per 10,000 (95% CI 2.68 to 5.34) benfluorex users or 3.22 per 10,000 (95% CI 2.48 to 4.39) person‐years at risk above the exposure threshold. While these findings are tentative, they are consistent with those obtained previously using very different methods. [ABSTRACT FROM AUTHOR]

Governments and other agencies seeking to tackle racism have been calling for better empirical evidence, including complaint data based on reports by people who have experienced racism. This approach requires much of those who face racism, often while offering little effective support or redress for them. There is a need to understand reporting or not reporting experiences of racism as a result of a complex interplay between different factors – as a (non-) reporting journey, rather than as a singular moment of decision. Reporting is at risk of remaining an ineffective strategy for responding to racism where the reporting pathways and support services are not sufficiently aligned with the expectations and needs of those who experience racism. This article discusses the findings of three place-based community engagement and research projects across four local municipalities in Melbourne. The projects examined locally specific community perspectives and expectations in relation to reporting pathways and support services for those experiencing racism. The analysis of this community input resulted in anti-racism roadmaps specific for each local area, which were co-developed with local communities. [ABSTRACT FROM AUTHOR]

Objective A limited range of neuropsychiatric symptoms have been reported in systemic autoimmune rheumatic diseases (SARDs), with varied symptom prevalence. This study aimed to investigate a wider range of potential symptoms than previous studies, compare patient self-reports with clinician estimates, and explore barriers to symptom identification. Methods Mixed methods were used. Data from SARDs patients (n  = 1853) were compared with controls (n  = 463) and clinicians (n  = 289). In-depth interviews (n  = 113) were analysed thematically. Statistical tests compared means of survey items between patients and controls, 8 different SARD groups, and clinician specialities. Results Self-reported lifetime prevalences of all 30 neuropsychiatric symptoms investigated (including cognitive, sensorimotor and psychiatric) were significantly higher in SARDs than controls. Validated instruments assessed 55% of SARDs patients as currently having depression and 57% anxiety. Barriers to identifying neuropsychiatric symptoms included: (i) limits to knowledge, guidelines, objective tests and inter-speciality cooperation; (ii) subjectivity, invisibility and believability of symptoms; and (iii) under-eliciting, under-reporting and under-documenting. A lower proportion of clinicians (4%) reported never/rarely asking patients about mental health symptoms than the 74% of patients who reported never/rarely being asked in clinic (P  < 0.001). Over 50% of SARDs patients had never/rarely reported their mental health symptoms to clinicians, a proportion underestimated at <10% by clinicians (P  < 0.001). Conclusion Neuropsychiatric symptom self-reported prevalences are significantly higher in SARDs than controls, and are greatly underestimated by most clinicians. Research relying on medical records and current guidelines is unlikely to accurately reflect patients' experiences of neuropsychiatric symptoms. Improved inter-speciality communication and greater patient involvement is needed in SARD care and research. [ABSTRACT FROM AUTHOR]

We examine spatial spillovers in violent crime and its under-reporting in Bogotá, Colombia, using a cuadrante (quadrant) level data. To model spatial spillovers, we use a spatial panel model with fixed effects, and to address under-reporting, we use the stochastic frontier approach as a tool. The novel statistical approach is combined with a database of police-reported crimes in Bogotá to examine how influential surrounding areas with high criminal offenses are on crime (under)reporting. The results suggest that spatial correlations are highly significant and that under-reporting is mainly related to interactions with other localities, which have important public policy implications. [ABSTRACT FROM AUTHOR]

Intellectual disability in India is substantially under-reported, especially amongst females. This study quantifies the prevalence and gender bias in household reporting of intellectual disability by estimating the age-and-gender specific prevalence of the intellectually disabled by education, Socio-Demographic Index (SDI) score, place of residence, (rural/urban) and income of household head. We estimated prevalence (per 100,000) at 179 (95% CI: 173 to 185) for males and 120 (95% CI: 115 to 125) for females. Gender differences declined sharply with increased education, was higher for lower ages and low income and varied little by state development. Under-identification and under-reporting due to stigma are two plausible reasons for the gender differences in prevalence that increase with age. [ABSTRACT FROM AUTHOR]

Sexual offence disclosures are on the rise, thought to be the result of growing numbers of prosecutions brought against well-known public figures and mobilisation of movements such as #MeToo. Despite this, data continue to indicate that most victim-survivors will never report their abuse. This study aimed to explore why women continue to decide not to report sexual assault to the police. Secondary data were collated and analysed, pertaining to survivor accounts of sexual assault, posted in response to a prominent online video entitled 'Women Tell Us Why They Didn't Report Their Sexual Assault'. Thematic analysis revealed three main themes regarding why women chose not to report: (1) Lack of faith in the Criminal Justice System (encompassing two sub-themes, no evidence and traumatisation of reporting), (2) Self-blame, and (3) Knowing the perpetrator. Practical applications and reforms concerning empathic police responses and CJS improvements surrounding timeliness, case progression, and conviction rates are discussed. [ABSTRACT FROM AUTHOR]

Purpose: Governments around the world have a shared responsibility for the management of occupational health and safety (OHS). The study aims to explore the under-reporting of OHS accidents by employees and employers in the construction industry in Ghana. Design/ Methodology/ Approach: The study used a cross-sectional survey design and quantitative and qualitative research techniques. Data was gathered via a questionnaire. The survey involved 250 site managers and operatives from Upper West and Upper East Regions. Significant factors that contribute to the under-reporting of construction-related accidents were identified and prioritized using descriptive statistics. The Linear Structural Relationships (LISREL) factor analysis was used to confirm the important factors. Findings: It was deduced from the findings that job security, workers' attitudes, education and training, blame culture, interpersonal relationships, poor safety culture, lack of management commitment, poor communication, and company's goal contribute significantly to the underreporting of OHS accidents within construction firms in Ghana. In the study, factors contributing to the under-reporting of construction site accidents to statutory authorities included education and training, the environment, politics/government, legal/regulations, and socio-cultural practices. Practical Implications: The findings will enable construction companies to make investments to develop accident reporting systems that are easier to use and more accessible. This may include developing mobile reporting apps, and training employees how to use the reporting apps and tools efficiently. Social Implications: Employee safety and well-being is one of the main societal ramifications. Policymakers can use the findings to develop more robust policies aimed at improving accident reporting and prevention measures in the construction industry. Originality and Value: This research offers valuable insights into the factors influencing the underreporting of occupational health and safety (OHS) accidents on construction sites. [ABSTRACT FROM AUTHOR]

Background and objectives. Blood exposure accidents (BEA) are one of the problems faced daily by health care personnel. Materials and methods. This study aims to determine the psycho-technical characteristics of the trivialization of BEA in health care facilities in the Tangier-Tetouan-Al Hoceima region in northern Morocco, and to identify the main causes of their underreporting. We conducted a cross-sectional, descriptive study for analytical purposes over a two-month period. A total of 117 professionals agreed to participate in the study. Results. Eighty-eight of them had been victims of a blood exposure accident (BEA). 65% were nurses, 33.3% of the respondents worked in health centers and only 31.6% declared this risk. The most significant mechanism for the occurrence of the accident was pricking during injections (64.1%). The most frequent reason for the trivialization of BEA was the complexity of the reporting procedure (38.5%), and the reporting rate was therefore very low. The underestimation of the risk was clearly perceived. No contamination was recorded and several determinants of the trivialization of BEA were revealed (lack of knowledge of the procedure, no notified seroconversion, etc.). Conclusions. This study initiates a reflection on the necessary actions to be carried out to encourage health care personnel to declare BEA as an occupational accident and to prevent the resulting occupational diseases.

Abstract It is well known that police recorded crime data is susceptible to substantial measurement error. However, despite its limitations, police data is widely used in regression models exploring the causes and effects of crime, which can lead to different types of bias. Here, we introduce a new R package (‘rcme’: Recounting Crime with Measurement Error) that can be used to facilitate sensitivity assessments of the impact of measurement error in analyses using police recorded crime rates across a wide range of settings. To demonstrate the potential of such sensitivity analysis, we explore the robustness of the effect of collective efficacy on criminal damage across Greater London’s neighbourhoods. We show how the crime reduction effect attributed to collective efficacy appears robust, even when most criminal damage incidents are not recorded by the police, and if we accept that under-recording rates are moderately affected by collective efficacy.

Abstract Background During the COVID-19 pandemic, the CoMix study, a longitudinal behavioral survey, was designed to monitor social contacts and public awareness in multiple countries, including Belgium. As a longitudinal survey, it is vulnerable to participants’ “survey fatigue”, which may impact inferences. Methods A negative binomial generalized additive model for location, scale, and shape (NBI GAMLSS) was adopted to estimate the number of contacts reported between age groups and to deal with under-reporting due to fatigue within the study. The dropout process was analyzed with first-order auto-regressive logistic regression to identify factors that influence dropout. Using the so-called next generation principle, we calculated the effect of under-reporting due to fatigue on estimating the reproduction number. Results Fewer contacts were reported as people participated longer in the survey, which suggests under-reporting due to survey fatigue. Participant dropout is significantly affected by household size and age categories, but not significantly affected by the number of contacts reported in any of the two latest waves. This indicates covariate-dependent missing completely at random (MCAR) in the dropout pattern, when missing at random (MAR) is the alternative. However, we cannot rule out more complex mechanisms such as missing not at random (MNAR). Moreover, under-reporting due to fatigue is found to be consistent over time and implies a 15-30% reduction in both the number of contacts and the reproduction number ( $$R_0$$ R 0 ) ratio between correcting and not correcting for under-reporting. Lastly, we found that correcting for fatigue did not change the pattern of relative incidence between age groups also when considering age-specific heterogeneity in susceptibility and infectivity. Conclusions CoMix data highlights the variability of contact patterns across age groups and time, revealing the mechanisms governing the spread/transmission of COVID-19/airborne diseases in the population. Although such longitudinal contact surveys are prone to the under-reporting due to participant fatigue and drop-out, we showed that these factors can be identified and corrected using NBI GAMLSS. This information can be used to improve the design of similar, future surveys.

AimsThe current study aims to investigate the consistency between the surveyees’ self-reported disease diagnosis and clinical assessment of eight major chronic conditions using community-based survey data collected in Xi’an, China in 2017. With a focus on under-reporting patients, we aim to explore its magnitude and associated factors, to provide an important basis for disease surveillance, health assessment and resource allocation, and public health decision-making and services.MethodsQuestionnaires were administered to collect self-reported chronic condition prevalence among the study participants, while physical examinations and laboratory tests were conducted for clinical assessment. For each of the eight chronic conditions, the sensitivity, specificity, under-reporting, over-reporting, and agreement were calculated. Log-binomial regression analysis was employed to identify potential factors that may influence the consistency of chronic condition reporting.ResultsA total of 2,272 participants were included in the analysis. Four out of the eight chronic conditions displayed under-reporting exceeding 50%. The highest under-reporting was observed for goiter [85.93, 95% confidence interval (CI): 85.25–86.62%], hyperuricemia (83.94, 95% CI: 83.22–84.66%), and thyroid nodules (72.89, 95% CI: 72.02–73.76%). Log-binomial regression analysis indicated that senior age and high BMI were potential factors associated with the under-reporting of chronic condition status in the study population.ConclusionThe self-reported disease diagnosis by respondents and clinical assessment data exhibit significant inconsistency for all eight chronic conditions. Large proportions of patients with multiple chronic conditions were under-reported in Xi’an, China. Combining relevant potential factors, targeted health screenings for high-risk populations might be an effective method for identifying under-reporting patients.

Background and objectives. Blood exposure accidents (BEA) are one of the problems faced daily by health care personnel. Materials and methods. This study aims to determine the psycho-technical characteristics of the trivialization of BEA in health care facilities in the Tangier-Tetouan-Al Hoceima region in northern Morocco, and to identify the main causes of their underreporting. We conducted a cross-sectional, descriptive study for analytical purposes over a two-month period. A total of 117 professionals agreed to participate in the study. Results. Eighty-eight of them had been victims of a blood exposure accident (BEA). 65% were nurses, 33.3% of the respondents worked in health centers and only 31.6% declared this risk. The most significant mechanism for the occurrence of the accident was pricking during injections (64.1%). The most frequent reason for the trivialization of BEA was the complexity of the reporting procedure (38.5%), and the reporting rate was therefore very low. The underestimation of the risk was clearly perceived. No contamination was recorded and several determinants of the trivialization of BEA were revealed (lack of knowledge of the procedure, no notified seroconversion, etc.). Conclusions. This study initiates a reflection on the necessary actions to be carried out to encourage health care personnel to declare BEA as an occupational accident and to prevent the resulting occupational diseases. [ABSTRACT FROM AUTHOR]

Background: Only 5–10% of all adverse drug reactions (ADRs) are reported. Mechanisms to support patient and public reporting offer numerous advantages to health care systems including increasing reporting rate. Theory-informed insights into the factors implicated in patient and public underreporting are likely to offer valuable opportunity for the development of effective reporting-interventions and optimization of existing systems. Aim: To collate, summarize and synthesize the reported behavioral determinants using the theoretical domains framework (TDF), that influence patient and public reporting of ADRs. Method: Cochrane, CINAHL, Web of science, EMBASE and PubMed were systematically searched on October 25th, 2021. Studies assessing the factors influencing public or patients reporting of ADRs were included. Full-text screening, data extraction and quality appraisal were performed independently by two authors. Extracted factors were mapped to TDF. Results: 26 studies were included conducted in 14 countries across five continents. Knowledge, social/professional role and identity, beliefs about consequences, and environmental context and resources, appeared to be the most significant TDF domains that influenced patient and public behaviors regarding ADR reporting. Conclusion: Studies included in this review were deemed of low risk of bias and allowed for identification of key behavioural determinants, which may be mapped to evidence-based behavioral change strategies that facilitate intervention development to enhance rates of ADR reporting. Aligning strategies should focus on education, training and further involvement from regulatory bodies and government support to establish mechanisms, which facilitate feedback and follow-ups on submitted reports. [ABSTRACT FROM AUTHOR]

It is well known that police recorded crime data is susceptible to substantial measurement error. However, despite its limitations, police data is widely used in regression models exploring the causes and effects of crime, which can lead to different types of bias. Here, we introduce a new R package ('rcme': Recounting Crime with Measurement Error) that can be used to facilitate sensitivity assessments of the impact of measurement error in analyses using police recorded crime rates across a wide range of settings. To demonstrate the potential of such sensitivity analysis, we explore the robustness of the effect of collective efficacy on criminal damage across Greater London's neighbourhoods. We show how the crime reduction effect attributed to collective efficacy appears robust, even when most criminal damage incidents are not recorded by the police, and if we accept that under-recording rates are moderately affected by collective efficacy. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, the CoMix study, a longitudinal behavioral survey, was designed to monitor social contacts and public awareness in multiple countries, including Belgium. As a longitudinal survey, it is vulnerable to participants' "survey fatigue", which may impact inferences. Methods: A negative binomial generalized additive model for location, scale, and shape (NBI GAMLSS) was adopted to estimate the number of contacts reported between age groups and to deal with under-reporting due to fatigue within the study. The dropout process was analyzed with first-order auto-regressive logistic regression to identify factors that influence dropout. Using the so-called next generation principle, we calculated the effect of under-reporting due to fatigue on estimating the reproduction number. Results: Fewer contacts were reported as people participated longer in the survey, which suggests under-reporting due to survey fatigue. Participant dropout is significantly affected by household size and age categories, but not significantly affected by the number of contacts reported in any of the two latest waves. This indicates covariate-dependent missing completely at random (MCAR) in the dropout pattern, when missing at random (MAR) is the alternative. However, we cannot rule out more complex mechanisms such as missing not at random (MNAR). Moreover, under-reporting due to fatigue is found to be consistent over time and implies a 15-30% reduction in both the number of contacts and the reproduction number ( R 0 ) ratio between correcting and not correcting for under-reporting. Lastly, we found that correcting for fatigue did not change the pattern of relative incidence between age groups also when considering age-specific heterogeneity in susceptibility and infectivity. Conclusions: CoMix data highlights the variability of contact patterns across age groups and time, revealing the mechanisms governing the spread/transmission of COVID-19/airborne diseases in the population. Although such longitudinal contact surveys are prone to the under-reporting due to participant fatigue and drop-out, we showed that these factors can be identified and corrected using NBI GAMLSS. This information can be used to improve the design of similar, future surveys. [ABSTRACT FROM AUTHOR]

Country reported case counts suggested a slow spread of SARS-CoV-2 in the initial phase of the COVID-19 pandemic in Africa. Owing to inadequate public awareness, unestablished monitoring practices, limited testing and stigmas, there might exist extensive under-ascertainment of the true number of cases, especially at the beginning of the novel epidemic. We developed a compartmentalized epidemiological model to track the early epidemics in 54 African countries. Data on the reported cumulative number of cases and daily confirmed cases were used to fit the model for the time period with no or little massive national interventions yet in each country. We estimated that the mean basic reproduction number is 2.02 (s.d. 0.7), with a range between 1.12 (Zambia) and 3.64 (Nigeria). The mean overall report rate was estimated to be 5.37% (s.d. 5.71%), with the highest 30.41% in Libya and the lowest 0.02% in São Tomé and Príncipe. An average of 5.46% (s.d. 6.4%) of all infected cases were severe cases and 66.74% (s.d. 17.28%) were asymptomatic ones. The estimated low reporting rates in Africa suggested a clear need for improved reporting and surveillance systems in these countries.

Objectives: Recognition of chronic kidney disease (CKD) is crucial in type 2 diabetes mellitus (T2DM). We conducted a nationwide epidemiological study to evaluate T2DM-associated CKD in Hungary between 2016 and 2020.Methods: Annual incidence and prevalence rates of registered CKD amongst all pharmacologically treated T2DM patients were analyzed in different age-groups by the central database of the Hungarian Health Insurance Fund Management. Statistical methods included Poisson regression, Bonferroni test, Chi-square test.Results: We found 499,029 T2DM patients and 48,902 CKD patients in 2016, and 586,075 T2DM patients and 38,347 CKD patients in 2020. The majority of all prevalent T2DM and CKD patients were older (aged 60–69 years: 34.1% and 25.8%; ≥70 years: 36.1% and 64.4%, respectively). The annual incidence of T2DM and incidence rates of CKD in T2DM decreased in 2017–2020 (p < 0.001). The annual prevalence of T2DM increased (p < 0.01), the prevalence rates of CKD in T2DM were low and decreased from 9.8% to 6.5% in 2016–2020 (p < 0.001).Conclusion: Incidence and prevalence of T2DM-associated CKD decreased significantly in Hungary in 2016–2020. Lower prevalence rates of CKD may suggest under-recognition and/or under-reporting.

India is dependent on police data as the only routinely recorded and publicly available data source on suicide. This correspondence considers some of the uses and limitations of using police suicide data in India and highlights how other low- and middle-income countries can potentially benefit from using police suicide data.

Background: Workers who experience language barriers are at increased risk of work‐related injuries and illnesses and face difficulties reporting these health problems to their employer and workers' compensation. In the existing occupational health and safety literature, however, such challenges are often framed in individual‐level terms. We identify systemic barriers to reporting among injured workers who experience language barriers within the varying contexts of Ontario and Quebec, Canada. Methods: This study merges data from two qualitative studies that investigated experiences with workers' compensation and return‐to‐work, respectively, for injured workers who experience language barriers. We conducted semi‐structured interviews with 39 workers and 70 stakeholders in Ontario and Quebec. Audio recordings were transcribed and coded using NVivo software. The data was analysed thematically and iteratively. Results: Almost all workers (34/39) had filed a claim, though most had initially delayed reporting their injuries or illnesses to their employer or to workers' compensation. Workers faced several obstacles to reporting, including confusion surrounding the cause and severity of injuries and illnesses; lack of information, misinformation, and disinformation about workers' compensation; difficulties accessing and interacting with care providers; fear and insecurity linked to precarity; claim suppression by employers; negative perceptions of, and experiences with, workers' compensation; and lack of supports. Language barriers amplified each of these difficulties, resulting in significant negative impacts in economic, health, and claim areas. Conclusion: Improving the linguistic and cultural competence of organizations and their representatives is insufficient to address under‐reporting among workers who experience language barriers. Efforts to improve timely reporting must tackle the policies and practices that motivate and enable under‐reporting for workers, physicians, and employers. [ABSTRACT FROM AUTHOR]

Both under-and over-nutrition are prevalent in patients with Crohn's Disease (CD). The aim of the present study was to evaluate dietary intake and compare it with relevant recommendations during active disease and remission, also taking into consideration the adequacy of energy reporting. Dietary quality was assessed through adherence to the Mediterranean diet and to the European dietary guidelines for cardiovascular disease prevention (CVD-score). Malnutrition was diagnosed with the GLIM criteria. There were 237 patients evaluated (54.9% males, 41.3 ± 14.1 years and 37.6% with active disease). In the total sample, high prevalence of overweight/obesity (61.6%) and low prevalence of malnutrition (11.4%) were observed, whereas 25.5% reported low protein intake in the sub-sample of adequate energy reporters. The mean MedDietScore was 28.0 ± 5.5 and the mean CVD-score was 5.25 ± 1.36, both reflecting moderate dietary quality. Patients with active disease reported higher prevalence of low protein intake, lower carbohydrate, fibers, fruits, vegetables, legumes, and sweets consumption and a lower MedDietScore compared to patients in remission. Consumption of fibers, fruits, vegetables, and legumes while in remission did not result in reaching the recommended intakes, and dietary quality was low as reflected by the MedDietScore. In conclusion, both protein undernutrition and energy overconsumption were prevalent in the current sample and overall patients adhered to a moderate quality diet irrespective of disease stage. [ABSTRACT FROM AUTHOR]

Individual records referring to personal interviews conducted for a survey on income in Modena during 2012 and tax year 2011 were matched with the corresponding records in the Italian Ministry of Finance databases containing fiscal income data for tax year 2011. The analysis of the resulting data set suggested that the fiscal income data were generally more reliable than the surveyed income data. Moreover, the obtained data set enabled identification of the factors determining over- and under-reporting, as well as measurement errors, through a comparison of the surveyed income data with the fiscal income data, only for suitable categories of interviewees, that is, taxpayers who are forced to respect the tax laws (the public sector) and taxpayers who have many evasion options (the private sector). The percentage of under-reporters (67.3%) was higher than the percentage of over-reporters (32.7%). Level of income, age, and education were the main regressors affecting measurement errors and the behaviours of tax evaders. Tax evasion and the impacts of personal factors affecting evasion were evaluated using various approaches. The average tax evasion amounted to 26.0% of the fiscal income. About 10% of the sample was made up of possible total tax evaders. [ABSTRACT FROM AUTHOR]

Under-reporting in cyber incidents is a well-established problem. Due to reputational risk and the consequent financial impact, a large proportion of incidents are never disclosed to the public, especially if they do not involve a breach of protected data. Generally, the problem of under-reporting is solved through a proportion-based approach, where the level of under-reporting in a data set is determined by comparison to data that is fully reported. In this work, cyber insurance claims data is used as the complete data set. Unlike most other work, however, our goal is to quantify under-reporting with respect to multiple dimensions: company revenue, industry, and incident categorization. The research shows that there is a dramatic difference in under-reporting—a factor of 100—as a function of these variables. Overall, it is estimated that only approximately 3% of all cyber incidents are accounted for in databases of publicly reported events. The output of this work is an under-reporting model that can be used to correct incident frequencies derived from data sets of publicly reported incidents. This diminishes the "barrier to entry" in the development of cyber risk models, making it accessible to researchers who may not have the resources to acquire closely guarded cyber insurance claims data. [ABSTRACT FROM AUTHOR]

A panel of 24 international experts met in July 2022 to discuss challenges associated with pertussis detection, monitoring, and vaccination in adults; conclusions from this meeting are presented. There has been a shift in the epidemiology of pertussis toward older children and adults. This shift has been attributed to the waning of infection- or vaccine-induced immunity, newer detection techniques causing detection bias, and possibly the replacement of whole-cell pertussis with acellular vaccines in high-income countries, which may lead to immunity waning more quickly. The burden of adult pertussis is still likely under-ascertained due to widespread under-recognition by healthcare professionals (HCPs), under-diagnosis, and under-reporting in this age group. Non-standardized testing guidance and varied case definitions have contributed to under-reporting. Key barriers to HCP engagement with the tetanus, diphtheria, and pertussis (Tdap) vaccine include low awareness, lack of time/funding, and lack of motivation due to low prioritization of Tdap.

The COVID-19 pandemic (SARS-CoV-2 virus) is the global crisis of our time. The absence of mass testing and the relevant presence of asymptomatic individuals causes the available data of the COVID-19 pandemic in Brazil to be largely under-reported regarding the number of infected individuals and deaths. We develop an adapted Susceptible-Infected-Recovered (SIR) model, which explicitly incorporates the under-reporting and the response of the population to public health policies (confinement measures, widespread use of masks, etc). Large amounts of uncertainty could provide misleading predictions of the COVID-19 spread. In this paper, we discuss the role of uncertainty in these model-based predictions, which is illustrated regarding three key aspects: (i) Assuming that the number of infected individuals is under-reported, we demonstrate anticipation regarding the infection peak. Furthermore, while a model with a single class of infected individuals yields forecasts with increased peaks, a model that considers both symptomatic and asymptomatic infected individuals suggests a decrease of the peak of symptomatic cases. (ii) Considering that the actual amount of deaths is larger than what is being registered, we demonstrate an increase of the mortality rates. (iii) When we consider generally under-reported data, we demonstrate how the transmission and recovery rate model parameters change qualitatively and quantitatively. We also investigate the “the uncertainty tripod”: under-reporting level in terms of cases, deaths, and the true mortality rate of the disease. We demonstrate that if two of these factors are known, the remainder can be inferred, as long as proportions are kept constant. The proposed approach allows one to determine the margins of uncertainty by assessments on the observed and true mortality rates.

Abstract Background Seasonal influenza has major implications for healthcare services as outbreaks often lead to high activity levels in health systems. Being able to predict when such outbreaks occur is vital. Mathematical models have extensively been used to predict epidemics of infectious diseases such as seasonal influenza and to assess effectiveness of control strategies. Availability of comprehensive and reliable datasets used to parametrize these models is limited. In this paper we combine a unique epidemiological dataset collected in Malta through General Practitioners (GPs) with a novel method using cross-sectional surveys to study seasonal influenza dynamics in Malta in 2014–2016, to include social dynamics and self-perception related to seasonal influenza. Methods Two cross-sectional public surveys (n = 406 per survey) were performed by telephone across the Maltese population in 2014–15 and 2015–16 influenza seasons. Survey results were compared with incidence data (diagnosed seasonal influenza cases) collected by GPs in the same period and with Google Trends data for Malta. Information was collected on whether participants recalled their health status in past months, occurrences of influenza symptoms, hospitalisation rates due to seasonal influenza, seeking GP advice, and other medical information. Results We demonstrate that cross-sectional surveys are a reliable alternative data source to medical records. The two surveys gave comparable results, indicating that the level of recollection among the public is high. Based on two seasons of data, the reporting rate in Malta varies between 14 and 22%. The comparison with Google Trends suggests that the online searches peak at about the same time as the maximum extent of the epidemic, but the public interest declines and returns to background level. We also found that the public intensively searched the Internet for influenza-related terms even when number of cases was low. Conclusions Our research shows that a telephone survey is a viable way to gain deeper insight into a population’s self-perception of influenza and its symptoms and to provide another benchmark for medical statistics provided by GPs and Google Trends. The information collected can be used to improve epidemiological modelling of seasonal influenza and other infectious diseases, thus effectively contributing to public health.

The under-reporting of sexual abuse reduces the chances of winning the battle against sexual abuse of women and children in Zimbabwe. It leaves girl children powerless and vulnerable, despite the country’s determination to put an end to injustice and gender discrimination in line with the Sustainable Development Goals (SDGs), in particular, SDG 5, which focuses on gender and equality, and SDG 16, which is concerned with justice and peace. The aim of this study was to explore the barriers to reporting sexual abuse in Ruwa. Informed by the human rights-based approach, the study adopted a quantitative research design. Survey data were solicited from 51 randomly selected female respondents. Results revealed that 69% of the respondents were abused, yet only 2% of the total respondents reported the abuse to authorities, while 67% did not report incidences of abuse. About 98% of respondents believed that most sexual abuse cases in Ruwa went unreported. Results also showed that barriers to reporting sexual abuses comprised cultural and economic factors, most of which were characterised by shame, embarrassment, and fear, as well as the desire to protect male breadwinners. The results are consistent with existing literature generalisations on sexual abuse, particularly in terms of the prevalence of sexual abuse and under-reporting. It is also argued that culture is the determinant factor for most of the barriers to reporting sexual abuse, as well as the effects of reporting. Based on the results and in view of promoting and protecting human rights associated with sexuality, the study recommends that local authorities and social institutions implement awareness programmes and campaigns on reporting sexual abuse in the community. Contribution: This study is the first of its kind in Ruwa. Its significance is embedded in how it reflects on the role played by culture, religion and societal views on matters of sexual abuse.

The COVID-19 pandemic has affected all countries in the world and brings a major disruption in our daily lives. Estimation of the prevalence and contagiousness of COVID-19 infections may be challenging due to under-reporting of infected cases. For a better understanding of such pandemic in its early stages, it is crucial to take into consideration unreported infections. In this study we propose a truncation model to estimate the under-reporting probabilities for infected cases. Hypothesis testing on the differences in truncation probabilities, that are related to the under-reporting rates, is implemented. Large sample results of the hypothesis test are presented theoretically and by means of simulation studies. We also apply the methodology to COVID-19 data in certain countries, where under-reporting probabilities are expected to be high. [ABSTRACT FROM AUTHOR]

Introduction: Pharmacovigilance plays an important role in the healthcare sector, in terms of health and economic burden. Studies on interns are limited and it is an aspect that requires further study. Aim: To evaluate the knowledge, attitude and perception of MBBS interns at a teaching hospital in southern India. Also to study the reasons for under-reporting of Adverse Drug Reactions (ADR). Materials and Methods: This questionnaire-based, cross-sectional study was conducted among the 112 MBBS interns at Konaseema Institute of Medical sciences and Research Foundation, Amalapuram, Andhra Pradesh, India, in December 2013. The interns were asked to complete 25 predesigned questionnaire based on the Knowledge, Attitude and Perception (KAP). The answered questionnaires were statistically analysed by using Microsoft Excel worksheet. Results: Out of total 112 MBBS interns, only 94 completed the questionnaire within the stipulated time. There were 41 males and 53 females, with a mean age of 25±2 years. The response rate was 83.9%. A 48 (51.1%) interns had come across Adverse Drug Reactions (ADR) cases during their practice, however, among them only 24 (50%) reported them. Difficulty to identify the causative drug was the major cause for under-reporting as per 23 (24.4%) interns. Majority (60.6%) were of the opinion that pharmacovigilance only covers drug-related side-effects, not other types of side-effects. Conclusion: Interns are the upcoming doctors, hence increased attention must be paid to their lack of pharmacovigilance knowledge in order to improve the clinical management and rational use of drugs. [ABSTRACT FROM AUTHOR]

• Black subjects are under-reported in lipid-lowering ASCVD outcomes trials. • Black subjects are under-represented in lipid-lowering ASCVD outcomes trials. • Inclusion of Black persons will help to address disparities in preventive care. Non-Hispanic (NH) Black participants have been under-represented in studies of cardiovascular disease. We sought to determine the trends of reporting and representation of NH Black subjects in randomized controlled trials (RCTs) of lipid-lowering therapies demonstrating atherosclerotic cardiovascular disease (ASCVD) risk reduction benefit. The electronic databases of MEDLINE, EMBASE and ClinicalTrials.gov were searched from 1990-2020. Studies of lipid-lowering therapies (i.e., statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors [PCSK9], and icosapent ethyl) with proven ASCVD benefit, sample sizes of at least 1000 subjects and follow-up of at least 1 year were included (40 RCTs, N=306 747 total participants). We examined articles and supplementary material for participant-level race data. Using United States disease prevalence data, the participation-to-prevalence ratio (PPR) metric was used to estimate the representation of NH Black subjects compared with their reported disease burden (i.e., < 0.8 indicated under-representation; > 1.2, over-representation; and 0.8 to <1.2, adequate representation). The median (interquartile range) number of participants per trial was 4871 (2434-10077). NH Black enrollees comprised 7.3% (95% CI, 0.9%-15.4%) of the total number of subjects reported. During the time intervals 1990-1995, 1996-2000, 2001-2005, 2006-2010, 2011-2015 and 2016-2020, NH Black participation was 0%, 1.1%, 4.4%, 4.8%, 0.2% and 0.7% respectively (P for trend <0.001). For statin trials, the participation of NH Black subjects was reported in 0 studies between 1990-1995 and in 9 of 28 trials from 1996-2020. For ezetimibe and icosapent ethyl, NH Black participants were reported in 0 of 3 and 0 of 1 studies, respectively. For trials of PCSK9 inhibitors, NH Black subjects were reported in 2 of 5 (40%). NH Black participants were under-represented compared with their disease burden in studies evaluating subjects with diabetes, hypercholesterolemia, stable coronary artery disease, and acute coronary syndrome (PPR < 0.8 for all). NH Black participants are markedly under-represented, and results are under-reported. The inclusion of population and disease specific representation of NH Black persons and their related social determinants of health will help to address the disparity in preventive care for this historically undertreated population. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Pharmacovigilance plays an important role in the healthcare sector, in terms of health and economic burden. Studies on interns are limited and it is an aspect that requires further study. Aim: To evaluate the knowledge, attitude and perception of pharmacovigilance awareness among MBBS interns at a teaching hospital in southern India. Also, to study the reasons for under-reporting of Adverse Drug Reactions (ADR). Materials and Methods: This questionnaire-based, cross-sectional study was conducted among the 112 MBBS interns at Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India, in December 2013. The interns were asked to complete 25 predesigned questionnaire based on the Knowledge, Attitude and Perception (KAP). The answered questionnaires were statistically analysed by using Microsoft Excel worksheet. Results: Out of total 112 MBBS interns, only 94 completed the questionnaire within the stipulated time. There were 41 males and 53 females, with a mean age of 25±2 years. The response rate was 83.9%. A 48 (51.1%) interns had come across Adverse Drug Reactions (ADR) cases during their practice, however, among them only 24 (50%) reported them. Difficulty to identify the causative drug, was the major cause for under-reporting as per 23 (24.4%) interns. Majority (60.6%) were of the opinion that, pharmacovigilance only covers drug-related side-effects, not other types of side-effects. Conclusion: Interns are the upcoming doctors, hence, increased attention must be paid to their lack of pharmacovigilance knowledge, in order to improve the clinical management and rational use of drugs.

BackgroundFood energy under-reporting is differentially distributed among populations. Currently, little is known about how mental health state may affect energy-adjusted nutrient intakes among food energy under-reporters.MethodsStratified analysis of energy-adjusted nutrient intake by mental health (poor vs. good) and age/sex was conducted using data from Canadian Community Health Survey (CCHS) respondents (14–70 years; n = 8,233) who were deemed as under-reporters based on Goldberg's cutoffs.ResultsMost were experiencing good mental health (95.2%). Among those reporting poor mental health, significantly lower energy-adjusted nutrient intakes tended to be found for fiber, protein, vitamins A, B2, B3, B6, B9, B12, C, and D, and calcium, potassium, and zinc (probability measures (p) < 0.05). For women (51–70 years), all micronutrient intakes, except iron, were significantly lower among those reporting poor mental health (p < 0.05). For men (31–50 years), B vitamin and most mineral intakes, except sodium, were significantly lower among those reporting poor mental health (p < 0.05). Among women (31–50 years) who reported poor mental health, higher energy-adjusted intakes were reported for vitamin B9 and phosphorus (p < 0.05).ConclusionsAmong food energy under-reporters, poor mental health tends to lower the report of specific energy-adjusted nutrient intakes that include ones critical for mental health. Future research is needed to discern if these differences may be attributed to deviations in the accurate reports of food intakes, measurement errors, or mental health states.

Background: Understanding the causes of patient safety incidents is essential for improving patient safety; therefore, reporting and analysis of these incidents is a key imperative. Despite its implemention more than 15 years ago, the institutionalization of incident reporting in Indonesian hospitals is far from satisfactory. The aim of this study was to analyze the factors responsible for under-reporting of patient safety incidents in Indonesian public hospitals from the perspectives of leaders of hospitals, government departments, and independent institutions. Methods: A qualitative research methodology was adopted for this study using semi-structured interviews of key informants. 25 participants working at nine organizations (government departments, independent institutions, and public hospitals) were interviewed. The interview transcripts were analyzed using a deductive analytic approach. Nvivo 10 was used to for data processing prior to thematic analysis. Results: The key factors contributing to the under-reporting of patient safety incidents were categorized as hospital related and nonhospital related (government or independent agency). The hospital-related factors were: lack of understanding, knowledge, and responsibility for reporting; lack of leadership and institutional culture of reporting incidents; perception of reporting as an additional burden. The nonhospital-related factors were: lack of feedback and training; lack of confidentiality mechanisms in the system; absence of policy safeguards to prevent any punitive measures against the reporting hospital; lack of leadership. Conclusion: Our study identified factors contributing to the under-reporting of patient safety incidents in Indonesia. The lack of government support and absence of political will to improve patient safety incident reporting appear to be the root causes of under-reporting. Our findings call for concerted efforts involving government, independent agencies, hospitals, and other stakeholders for instituting reforms in the patient safety incident reporting system.

Abstract Objectives Cutaneous leishmaniasis is a vector-borne parasitic disease whose lasting scars can cause stigmatization and depressive symptoms. It is endemic in remote rural areas and its incidence is under-reported, while the effectiveness, as opposed to efficacy, of its treatments is largely unknown. Here we present the data management plan (DMP) of a project which includes mHealth tools to address these knowledge gaps in Colombia. The objectives of the DMP are to specify the tools and procedures for data collection, data transfer, data entry, creation of analysis dataset, monitoring and archiving. Results The DMP includes data from two mobile apps: one implements a clinical prediction rule, and the other is for follow-up and treatment of confirmed cases. A desktop interface integrates these data and facilitates their linkage with other sources which include routine surveillance as well as paper and electronic case report forms. Multiple user and programming interfaces are used, as well as multiple relational and non-relational database engines. This DMP describes the successful integration of heterogeneous data sources and technologies. However the complexity of the project meant that the DMP took longer to develop than expected. We describe lessons learned which could be useful for future mHealth projects.

Aim: To test (1) if there was a change in self‐reported lifetime prevalence of meth/amphetamine use by birth cohort and (2) if the extent of under‐reporting of meth/amphetamine use was associated with the proportion of the population who nominated meth/amphetamine as a drug problem. Design Observational study using seven waves of repeated cross‐sectional nationally representative household surveys between 2001 and 2019. Setting: Australia. Participants: Participants were from three birth cohorts: 1951–60 (age 68–77 at the 2019 survey; n = 29 458; 55% female), 1961–1970 (age 58–67; n = 29 859; 57% female) and 1971–1980 (age 48–57; n = 28 758; 59% female). Data were weighted to align the sample to the Australian population. Measurements Past year meth/amphetamine use; under‐reporting of lifetime meth/amphetamine use in each birth cohort, year and survey stratum (operationalised as the difference between self‐reported lifetime prevalence in 2001 and that of each subsequent year); proportion of the population who nominated meth/amphetamine as a drug problem in each birth cohort, year and survey stratum. Under‐reporting was regressed on the proportion of people holding negative attitude towards meth/amphetamine. Survey year and birth cohort were adjusted for. Findings Between 2001 and 2019, the lifetime prevalence of meth/amphetamine decreased from 6.1% (95% CI = 5.3–6.9) to 1.7% (95% CI = 1.2–2.2) in the 1951–1960 birth cohort (p < 0.001), from 13.0% (95% CI = 12.0–14.1) to 4.4% (95% CI = 3.7–5.2) in the 1961–1970 birth cohort (p < 0.001) and from 21.4% (95% CI = 19.9–22.9) to 11.2% (95% CI = 10.0–12.4) in the 1971–1980 birth cohort (p < 0.001). The proportion who nominated meth/amphetamine as a 'drug problem' increased significantly in all three cohorts (all p < 0.001) and the degree of under‐reporting of meth/amphetamine use was significantly associated with proportion of people who nominated meth/amphetamine as the 'drug problem' (b = 0.09, SE = 0.01, p < 0.001). Conclusion: In Australia, the actual prevalence of lifetime meth/amphetamine use may be two‐ to fourfold higher than that estimated in the most recent national household surveys (2019). The level of under‐reporting is strongly associated with increasing negative attitudes towards methylamphetamine and d‐amphetamine use over the same period. [ABSTRACT FROM AUTHOR]

WHO estimates that nearly 40% of all patients with TB are under-reported to local or national TB surveillance programs every year. Indonesian TB Jetset (Research Network) in 2018 stated Indonesia ranked 2nd in the top ranking of tuberculosis case discovery, in Indonesia in 2017 the incidence of TB cases was 1,020,000, the number of cases detected was 710,000 or (70%), so that 310,000 or 30% undetected. This study aims to determine what influences the occurrence of under-reporting cases Hospital TB in Kudus and develop predictive index of under-reporting tuberculosis. Moreover, this study is expected to help eliminate the under-reporting cases 10%rate of tuberculosis that occurred in Kudus from the 44% proportion that occurred nationally based on the MDGs 2017 WHO targets and the targets of the national TB control program contained in the 2014 National Tuberculosis Control Guidelines. This study uses a mix-method of sequential explanatory design. In this quantitative study, we assessed nine indicators of unreported tuberculosis cases to determine how many indicators were associated with unreported cases. The number of samples in this quantitative study was 700 tuberculosis cases recorded at SITB DKK Kudus Regency and medical record data for tuberculosis cases in seven hospitals in Kudus. Meanwhile, qualitative research explores perceptions and information from medical personnel and hospital doctors regarding the reasons for choosing the underreporting case indicator. The number of informants in the qualitative research was 35 informants consisting of specialist doctors, general practitioners, nurses and hospital staff. Multilevel logistic regression analysis was performed for quantitative data, and content analysis for qualitative data. The findings of the quantitative and qualitative sections of the study were mixed in interpretation. The results showed that there were six indicators that affected under-reporting including: Competency of doctors in SITB was good (OR=0.09; CI95%= 0.05 to 0.17; p<001), Competence of health workers in SITB was good (OR=0.05; CI95% = 0.02 to 0.09; p<001), Commitment of health workers in SITB was strong (OR=0.13; 95% CI= 0.07 to 0.24; p<001), and AFB positive patient status (OR=0.35; 95% CI= 0.18 to 0.67; p=0.002). While the results of the qualitative research support the finding that most health workers and doctors who handle tuberculosis cases in hospitals in Kudus do not have SITB certificates, both nationally and regionally, only a few have attended training and have certificates. There is no integration between the SIM Hospital with SITB Hospital or DKK which causes the occurrence of under-reporting of high tuberculosis cases in Kudus. It can be concluded that there are six indices associated with underreporting cases of tuberculosis in Kudus Hospital. [ABSTRACT FROM AUTHOR]

The applicants’ self-declaration of medical history is crucial for safety. Some evidence indicates that under-reporting of medical conditions exists. However, the magnitude in a population of aviation personnel has not been reported earlier. METHODS: A total of 9941 applicants for medical certificate/attestation for aviation-related safety functions during the last 5 yr up to December 2019 were registered at the Civil Aviation Authority Norway. E-mail addresses were known for 9027 of these applicants, who were invited to participate in a web-based survey. RESULTS: Among the 1616 respondents, 726 (45%) were commercial pilots, 457 (28%) private pilots, 272 (17%) air traffic controllers, and the remaining were cabin crew or crew in aerodrome/helicopter flight information service (AFIS or HFIS, respectively). A total of 108 were initial applicants. The age group 50+ constituted the largest proportion of respondents (53%). Aeromedical certification in general was believed to improve flight safety “to a high” or “very high extent” by 64% of the respondents. A total of 188 individuals (12%) admitted having under-reported information related to one or more categories, including mental (3%) or physical health (4%), medications (2%), and drug use, including alcohol use (5%). Among these, 21 participants believed their own under-reporting “to some” or “to a high extent” affected flight safety. In total 50% of noninitial applicants reported that they knew colleagues who had under-reported information. Analyses revealed that being a commercial pilot showed a higher risk for under-reporting compared with other classes and the perception of aeromedical examiners in a supportive or authoritative role reduced the risk. CONCLUSIONS: Under-reporting of medical conditions could be significant in aviation. Further studies should be conducted to investigate the true extent of under-reporting and its impact on flight safety and what mitigating measures might be recommended. [ABSTRACT FROM AUTHOR]

Abstract Background Genital warts are a common and highly contagious sexually transmitted disease. They have a large economic burden and affect several aspects of quality of life. Incidence data underestimate the real occurrence of genital warts because this infection is often under-reported, mostly due to their specific characteristics such as the asymptomatic course. Methods Genital warts cases for the analysis were obtained from the Catalan public health system database (SIDIAP) for the period 2009-2016. People under 15 and over 94 years old were excluded from the analysis as the incidence of genital warts in this population is negligible. This work introduces a time series model based on a mixture of two distributions, capable of detecting the presence of under-reporting in the data. In order to identify potential differences in the magnitude of the under-reporting issue depending on sex and age, these covariates were included in the model. Results This work shows that only about 80% in average of genital warts incidence in Catalunya in the period 2009-2016 was registered, although the frequency of under-reporting has been decreasing over the study period. It can also be seen that this issue has a deeper impact on women over 30 years old. Conclusions Although this study shows that the quality of the registered data has improved over the considered period of time, the Catalan public health system is underestimating genital warts real burden in almost 10,000 cases, around 23% of the registered cases. The total annual cost is underestimated in about 10 million Euros respect the 54 million Euros annually devoted to genital warts in Catalunya, representing 0.4% of the total budget.