Publications by authors named "Martin McKee"

1,039 Publications

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A look into the future of the COVID-19 pandemic in Europe: an expert consultation.

Lancet Reg Health Eur 2021 Jul 30:100185. Epub 2021 Jul 30.

Dublin City University, Dublin, Ireland.

How will the coronavirus disease 2019 (COVID-19) pandemic develop in the coming months and years? Based on an expert survey, we examine key aspects that are likely to influence the COVID-19 pandemic in Europe. The challenges and developments will strongly depend on the progress of national and global vaccination programs, the emergence and spread of variants of concern (VOCs), and public responses to non-pharmaceutical interventions (NPIs). In the short term, many people remain unvaccinated, VOCs continue to emerge and spread, and mobility and population mixing are expected to increase. Therefore, lifting restrictions too much and too early risk another damaging wave. This challenge remains despite the reduced opportunities for transmission given vaccination progress and reduced indoor mixing in summer 2021. In autumn 2021, increased indoor activity might accelerate the spread again, whilst a necessary reintroduction of NPIs might be too slow. The incidence may strongly rise again, possibly filling intensive care units, if vaccination levels are not high enough. A moderate, adaptive level of NPIs will thus remain necessary. These epidemiological aspects combined with economic, social, and health-related consequences provide a more holistic perspective on the future of the COVID-19 pandemic.
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http://dx.doi.org/10.1016/j.lanepe.2021.100185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8321710PMC
July 2021

Does COVID-19 vaccination improve mental health? A difference-in-difference analysis of the Understanding Coronavirus in America study.

medRxiv 2021 Jul 28. Epub 2021 Jul 28.

Background: Mental health problems increased during the COVID-19 pandemic. Knowledge that one is less at risk after being vaccinated may alleviate distress, but this hypothesis remains unexplored. Here we test whether psychological distress declined in those vaccinated against COVID-19 in the US and whether changes in perceived risk mediated any association.

Methods: A nationally-representative cohort of U.S. adults (N=5,792) in the Understanding America Study were interviewed every two weeks from March 2020 to June 2021 (28 waves). Difference-in-difference regression tested whether getting vaccinated reduced distress (PHQ-4 scores), with mediation analysis used to identify potential mechanisms, including perceived risks of infection, hospitalization, and death.

Results: Vaccination was associated with a 0.09 decline in distress scores (95% CI:-0.15 to -0.04) (0-12 scale), a 5.7% relative decrease compared to mean scores in the wave prior to vaccination. Vaccination was also associated with an 8.44 percentage point reduction in perceived risk of infection (95% CI:-9.15% to -7.73%), a 7.44-point reduction in perceived risk of hospitalization (95% CI:-8.07% to -6.82%), and a 5.03-point reduction in perceived risk of death (95% CI:-5.57% to -4.49%). Adjusting for risk perceptions decreased the vaccination-distress association by two-thirds. Event study models suggest vaccinated and never vaccinated respondents followed similar PHQ-4 trends pre-vaccination, diverging significantly post-vaccination. Analyses were robust to individual and wave fixed effects, time-varying controls, and several alternative modelling strategies. Results were similar across sociodemographic groups.

Conclusion: Receiving a COVID-19 vaccination was associated with declines in distress and perceived risks of infection, hospitalization, and death. Vaccination campaigns could promote these additional benefits of being vaccinated.
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http://dx.doi.org/10.1101/2021.07.19.21260782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328069PMC
July 2021

Incentivising doctor attendance in rural Bangladesh: a latent class analysis of a discrete choice experiment.

BMJ Glob Health 2021 07;6(7)

Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.

Objective: Doctor absenteeism is widespread in Bangladesh, and the perspectives of the actors involved are insufficiently understood. This paper sought to elicit preferences of doctors over aspects of jobs in rural areas in Bangladesh that can help to inform the development of packages of policy interventions that may persuade them to stay at their posts.

Methods: We conducted a discrete choice experiment with 308 doctors across four hospitals in Dhaka, Bangladesh. Four attributes of rural postings were included based on a literature review, qualitative research and a consensus-building workshop with policymakers and key health-system stakeholders: relationship with the community, security measures, attendance-based policies and incentive payments. Respondents' choices were analysed with mixed multinomial logistic and latent class models and were used to simulate the likely uptake of jobs under different policy packages.

Results: All attributes significantly impacted doctor choices (p<0.01). Doctors strongly preferred jobs at rural facilities where there was a supportive relationship with the community (β=0.93), considered good attendance in education and training (0.77) or promotion decisions (0.67), with functional security (0.67) and higher incentive payments (0.5 per 10% increase of base salary). Jobs with disciplinary action for poor attendance were disliked by respondents (-0.63). Latent class analysis identified three groups of doctors who differed in their uptake of jobs. Scenario modelling identified intervention packages that differentially impacted doctor behaviour and combinations that could feasibly improve doctors' attendance.

Conclusion: Bangladeshi doctors have strong but varied preferences over interventions to overcome absenteeism. We generated evidence suggesting that interventions considering the perspective of the doctors themselves could result in substantial reductions in absenteeism. Designing policy packages that take account of the different situations facing doctors could begin to improve their ability and motivation to be present at their job and generate sustainable solutions to absenteeism in rural Bangladesh.
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http://dx.doi.org/10.1136/bmjgh-2021-006001DOI Listing
July 2021

Association between disability-related budget reductions and increasing drug-related mortality across local authorities in Great Britain.

Soc Sci Med 2021 Jul 13;284:114225. Epub 2021 Jul 13.

Dondena Centre for Research on Social Dynamics and Public Policy, Bocconi University, Milan, Italy.

Background: Drug-related mortality in the UK rose markedly after 2012. Here we test the hypothesis that cuts to disability-related spending were associated with increased drug-related mortality across local governments in Great Britain.

Methods: We regressed changes in drug-related death rates (years 2010-12 versus 2015-17) on local government disability-related budget reductions, adjusting for a range of regional, demographic, and economic factors. Budget reductions are captured with a combined measure of financial losses due to Incapacity Benefit and Disability Living Allowance reforms, expressed in pounds sterling per capita, per year. 364 local authorities across England, Scotland, and Wales were included in the study.

Findings: Greater budget reductions were associated with greater increases in drug-related death rates. In the unadjusted model, each £100 per capita budget reduction was associated with an increase in drug-related death rates of 3.30 per 100 000 population (95% CI: 2.43 to 4.17). The magnitude of the association increased after adjusting for region and demographic factors (b = 4.84; 95% CI: 3.26 to 6.43). The association remained statistically significant after adjusting for a full set of controls, including baseline and trends in unemployment rates, median hourly pay, and gross disposable household income per capita (b = 4.41; 95% CI: 2.57 to 6.24).

Conclusion: Deeper cuts to local government spending in Great Britain in the 2010s were associated with larger increases in drug-related deaths.
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http://dx.doi.org/10.1016/j.socscimed.2021.114225DOI Listing
July 2021

Prevalence and changes in food-related hardships by socioeconomic and demographic groups during the COVID-19 pandemic in the UK: A longitudinal panel study.

Lancet Reg Health Eur 2021 Jul;6:100125

Dondena Centre for Research on Social Dynamics and Public Policy and Department of Social and Political Sciences, Bocconi University, Milan, Italy.

Background: Food insecurity concerns have featured prominently in the UK response to the COVID-19 pandemic. We assess changes in the prevalence of food-related hardships in the UK population from April to July 2020.

Method: We analysed longitudinal data on food-related hardships for 11,104 respondents from the April-July 2020 waves of the Understanding Society COVID-19 web survey with linked data from the 2017-9 wave of the annual Understanding Society survey. Outcome variables were reports of being hungry but not eating and of being unable to eat healthy and nutritious food in the last week, which were adapted from the Food Insecurity Experience Scale. We used unadjusted estimates to examine changes in population prevalence and logistic regression to assess the association between employment transitions and both outcomes at the individual level.

Findings: The prevalence of reporting an inability to eat healthy or nutritious food rose from 3•2% in April to 16•3% in July 2020. The largest increases in being unable to eat healthy or nutritious food were among Asian respondents, the self-employed, and 35-44-year-olds. The prevalence of being hungry but not eating rose from 3•3% in April to 5•1% in July, with the largest increases observed among unemployed individuals below age 65. Those moving from employment to unemployment had higher odds of being hungry but not eating in the last week relative to furloughed individuals (OR = 2•2; p < 0•05; 95% CI: 1•1 to 4•2) and to the persistently employed (OR = 3•5; p < 0•001; 95% CI: 1•8 to 6•9), adjusting for age, highest qualification in 2017-19, net household income in 2017-19 (equivalized), gender, race/ethnicity, number children at home (aged 0-4, 5-15, and 16-18), cohabitation status, and government office region. Respondents moving from employment to unemployment also had higher odds of reporting an inability to eat healthy and nutritious food relative to furloughed individuals (OR = 1•9; p < 0•05; 95% CI: 1•4 to 3•2) and to the persistently employed (OR = 2•0; p < 0•01; 95% CI: 1•2 to 3•4). No statistically significant differences were found between furloughed individuals and the persistently employed in their probability of reporting either outcome.

Interpretation: Food-related hardships increased substantially in the UK between April and July 2020, largely driven by reports of an inability to eat healthy and nutritious food. The Coronavirus Job Retention Scheme and Self-Employment Income Support Scheme appeared to have conferred some protection, but more could have been done to mitigate the problems we describe in obtaining affordable food.

Funding: DS is funded by the Wellcome Trust investigator award. JK and DS are funded by the European Research Council n. 313590 - HRES. VT is funded by the European Research Council n. 694145- IFAMID.
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http://dx.doi.org/10.1016/j.lanepe.2021.100125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291709PMC
July 2021

Regional International Organizations and Health: A Framework for Analysis.

J Health Polit Policy Law 2021 Jul 15. Epub 2021 Jul 15.

London School of Hygiene and Tropical Medicine.

Context: Regional international organizations, from the South African Development Community (SADC) to the European Union (EU), are organizations that promote cooperation among countries in a specific region of the world. Asking what RIOs do to health and health policy by looking only at their formal health policies can understate their effects (e.g., a free trade agreement with no stated health goals can affect health policy) and overstate their effects (as with agreements full of ambition that did not deliver much).

Methods: We adopt a "three faces" framework that identifies their direct health policies, the effects of their trade and market policies, and their effects on health via fiscal governance of their member states in order to better capture their health impact. We tested the usefulness of the framework by examining the Association of Southeast Asian Nations (ASEAN), EU, North American Free Trade Agreement (NAFTA/USMCA), SADC, and the Union of South American Nations (UNASUR).

Findings: All RIOs had some impact on health systems and policies; and, in many cases, the principal policies were not identified as health policy.

Conclusions: Such a framework will be useful in understanding their effects on health systems and policies because it captures indirect and even unintended health effects in a way that permits development of explanatory theories.
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http://dx.doi.org/10.1215/03616878-9417456DOI Listing
July 2021

Macro level influences on strategic responses to the COVID-19 pandemic - an international survey and tool for national assessments.

J Glob Health 2021 Jul 1;11:05011. Epub 2021 Jul 1.

National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College, Hammersmith Campus, London, UK.

Background: Variation in the approaches taken to contain the SARS-CoV-2 (COVID-19) pandemic at country level has been shaped by economic and political considerations, technical capacity, and assumptions about public behaviours. To address the limited application of learning from previous pandemics, this study aimed to analyse perceived facilitators and inhibitors during the pandemic and to inform the development of an assessment tool for pandemic response planning.

Methods: A cross-sectional electronic survey of health and non-health care professionals (5 May - 5 June 2020) in six languages, with respondents recruited via email, social media and website posting. Participants were asked to score inhibitors (-10 to 0) or facilitators (0 to +10) impacting country response to COVID-19 from the following domains - Political, Economic, Sociological, Technological, Ecological, Legislative, and wider Industry (the PESTELI framework). Participants were then asked to explain their responses using free text. Descriptive and thematic analysis was followed by triangulation with the literature and expert validation to develop the assessment tool, which was then compared with four existing pandemic planning frameworks.

Results: 928 respondents from 66 countries (57% health care professionals) participated. Political and economic influences were consistently perceived as powerful negative forces and technology as a facilitator across high- and low-income countries. The 103-item tool developed for guiding rapid situational assessment for pandemic planning is comprehensive when compared to existing tools and highlights the interconnectedness of the 7 domains.

Conclusions: The tool developed and proposed addresses the problems associated with decision making in disciplinary silos and offers a means to refine future use of epidemic modelling.
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http://dx.doi.org/10.7189/jogh.11.05011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8248749PMC
July 2021

Mobility restrictions were associated with reductions in COVID-19 incidence early in the pandemic: evidence from a real-time evaluation in 34 countries.

Sci Rep 2021 07 2;11(1):13717. Epub 2021 Jul 2.

London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.

Most countries have implemented restrictions on mobility to prevent the spread of Coronavirus disease-19 (COVID-19), entailing considerable societal costs but, at least initially, based on limited evidence of effectiveness. We asked whether mobility restrictions were associated with changes in the occurrence of COVID-19 in 34 OECD countries plus Singapore and Taiwan. Our data sources were the Google Global Mobility Data Source, which reports different types of mobility, and COVID-19 cases retrieved from the dataset curated by Our World in Data. Beginning at each country's 100th case, and incorporating a 14-day lag to account for the delay between exposure and illness, we examined the association between changes in mobility (with January 3 to February 6, 2020 as baseline) and the ratio of the number of newly confirmed cases on a given day to the total number of cases over the past 14 days from the index day (the potentially infective 'pool' in that population), per million population, using LOESS regression and logit regression. In two-thirds of examined countries, reductions of up to 40% in commuting mobility (to workplaces, transit stations, retailers, and recreation) were associated with decreased cases, especially early in the pandemic. Once both mobility and incidence had been brought down, further restrictions provided little additional benefit. These findings point to the importance of acting early and decisively in a pandemic.
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http://dx.doi.org/10.1038/s41598-021-92766-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8253807PMC
July 2021

Lessons from countries implementing find, test, trace, isolation and support policies in the rapid response of the COVID-19 pandemic: a systematic review.

BMJ Open 2021 06 29;11(7):e047832. Epub 2021 Jun 29.

Division of Infection and Immunity, University College London, London, UK.

Objective: To systematically learn lessons from the experiences of countries implementing find, test, trace, isolate, support (FTTIS) in the first wave of the COVID-19 pandemic.

Design, Data Sources And Eligibility Criteria: We searched MEDLINE (PubMed), Cochrane Library, SCOPUS and JSTOR, initially between 31 May 2019 and 21 January 2021. Research articles and reviews on the use of contact tracing, testing, self-isolation and quarantine for COVID-19 management were included in the review.

Data Extraction And Synthesis: We extracted information including study objective, design, methods, main findings and implications. These were tabulated and a narrative synthesis was undertaken given the diverse research designs, methods and implications.

Results: We identified and included 118 eligible studies. We identified the core elements of an effective find, test, trace, isolate, support (FTTIS) system needed to interrupt the spread of a novel infectious disease, where treatment or vaccination was not yet available, as pertained in the initial stages of the COVID-19 pandemic. We report methods used to shorten case finding time, improve accuracy and efficiency of tests, coordinate stakeholders and actors involved in an FTTIS system, support individuals isolating and make appropriate use of digital tools.

Conclusions: We identified in our systematic review the key components of an FTTIS system. These include border controls, restricted entry, inbound traveller quarantine and comprehensive case finding; repeated testing to minimise false diagnoses and pooled testing in resource-limited circumstances; extended quarantine period and the use of digital tools for contact tracing and self-isolation. Support for mental or physical health and livelihoods is needed for individuals undergoing self-isolation/quarantine. An integrated system with rolling-wave planning can best use effective FTTIS tools to respond to the fast-changing COVID-19 pandemic. Results of the review may inform countries considering implementing these measures.
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http://dx.doi.org/10.1136/bmjopen-2020-047832DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251680PMC
June 2021

Disability and psychological distress in nine countries of the former Soviet Union.

J Affect Disord 2021 09 2;292:782-787. Epub 2021 Jun 2.

Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.

Background: People with disabilities (PWD) are at increased risk of poor mental health. However, this association and the pathways involved remain under-researched in many parts of the world. This study examined the association between disability and psychological distress in nine countries of the former Soviet Union (FSU).

Methods: Data were analysed from 18,000 adults aged ≥18 years collected during the Health in Times of Transition (HITT) survey undertaken in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine in 2010 and 2011. Information was obtained on disability status, the severity of the disability and psychological distress. Logistic regression analysis was used to estimate associations.

Results: In a fully adjusted combined country analysis, disability was associated with over two times higher odds for psychological distress (odds ratio [OR]: 2.19, 95% confidence interval [CI]: 1.86-2.58). The strength of the association varied across the individual countries. Among PWD more severe disability was associated with significantly higher odds for psychological distress (OR: 2.12, 95%CI: 1.26-3.55).

Limitations: The data were cross-sectional and disability status was self-reported, possibly resulting in underreporting.

Conclusions: Disability is associated with worse psychological health in FSU countries, especially among those with more severe disabilities. As poor mental health may also increase the risk of negative outcomes in PWD, this finding highlights the importance of the early detection and treatment of mental disorders in PWD in these countries.
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http://dx.doi.org/10.1016/j.jad.2021.05.061DOI Listing
September 2021

A public health approach to gambling regulation: countering powerful influences.

Lancet Public Health 2021 Aug 22;6(8):e614-e619. Epub 2021 Jun 22.

School of Psychology, University of Birmingham, Birmingham, UK.

Often portrayed as a harmless leisure activity in the UK, gambling is being increasingly recognised as a public health concern. However, a gambling policy system that explicitly tackles public health concerns and confronts the dependencies and conflicts of interest that undermine the public good is absent in the UK. Although there is a window of opportunity to change the gambling policy system, with the UK Government's launch of a review of the Gambling Act 2005, the adoption of a comprehensive and meaningful public health approach is not guaranteed. Too often, government policy has employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling. In view of the well described commercial determinants of health and corporate behaviour, an immense effort will be needed to shift the gambling discourse to protect public health. In this Viewpoint, we seek to advance this agenda by identifying elements that need challenging and stimulating debate.
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http://dx.doi.org/10.1016/S2468-2667(21)00098-0DOI Listing
August 2021

Incarceration and mortality in the United States.

SSM Popul Health 2021 Sep 1;15:100827. Epub 2021 Jun 1.

University of Massachusetts Amherst, Department of Economics, Crotty Hall, 412 North Pleasant Street, University of Massachusetts, Amherst, MA, 01002, USA.

The ongoing COVID-19 pandemic has spotlighted the role of America's overcrowded prisons as vectors of ill health, but robust analyses of the degree to which high rates of incarceration impact population-level health outcomes remain scarce. In this paper, we use county-level panel data from 2927 counties across 43 states between 1983 and 2014 and a novel instrumental variable technique to study the causal effect of penal expansion on age-standardised cause-specific and all-cause mortality rates. We find that higher rates of incarceration have substantively large effects on deaths from communicable, maternal, neonatal, and nutritional diseases in the short and medium term, whilst deaths from non-communicable disease and from all causes combined are impacted in the short, medium, and long run. These findings are further corroborated by a between-unit analysis using coarsened exact matching and a simulation-based regression approach to predicting geographically anchored mortality differences.
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http://dx.doi.org/10.1016/j.ssmph.2021.100827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193150PMC
September 2021

Disability and loneliness in nine countries of the former Soviet Union.

Disabil Health J 2021 May 28:101123. Epub 2021 May 28.

Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.

Background: People with disabilities (PWD) often face structural and other barriers to community involvement and may therefore be at risk of loneliness. Yet, so far, this issue has received little attention.

Objective: This cross-sectional study aimed to examine the association between disability and loneliness in nine countries of the former Soviet Union (FSU).

Methods: Data were analyzed from 18000 respondents aged ≥18 that came from the Health in Times of Transition (HITT) survey that was undertaken in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2010/11. Respondents reported on whether they had a disability (no/yes) and its severity. A single-item question was used to assess loneliness. Logistic regression analysis was used to examine the associations.

Results: Across the countries, 6.8% of respondents reported being disabled. In a fully adjusted combined country analysis, disability was associated with higher odds for loneliness (odds ratio: 1.30, 95% confidence interval: 1.06-1.60). In an analysis restricted to PWD, individuals in the most severe disability category (Group 1) had over two times higher odds for loneliness when compared to those in the least severe disability category (Group 3).

Conclusions: Disability is associated with higher odds for reporting loneliness in the FSU countries and this association is especially strong among those who are more severely disabled. An increased focus on the relationship between disability and loneliness is now warranted given the increasing recognition of loneliness as a serious public health problem that is associated with a number of detrimental outcomes.
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http://dx.doi.org/10.1016/j.dhjo.2021.101123DOI Listing
May 2021

E-cigarette manufacturers' compliance with clinical trial reporting expectations: a case series of registered trials by Juul Labs.

Tob Control 2021 Jun 14. Epub 2021 Jun 14.

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.

Background: Electronic cigarettes (e-cigarettes) are a frequently debated topic in public health. It is essential that clinical trials examining e-cigarettes are fully and accurately reported, especially given long-standing concerns about tobacco industry research. We assess the reporting of clinical trials sponsored by Juul Labs, the largest e-cigarette company in the USA, against accepted reporting standards.

Methods: We searched ClinicalTrials.gov for all trials sponsored by Juul Labs and determined those with registry data consistent with coverage by the Food and Drug Administration (FDA) Amendments Act 2007 (FDAAA). For trials with a primary completion date more than 1 year earlier, we searched ClinicalTrials.gov, the academic literature and a Juul-funded research database (JLI Science) for results. For located results, we compared reported outcomes with registered outcomes in line with Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines.

Results: We located five registered trials sponsored by Juul Labs that appeared covered by the FDAAA 2007 in the public data. All five trials did not have results available on ClinicalTrials.gov. We found one publication and four poster presentations reporting results for four of the five covered trials outside of ClinicalTrials.gov. Of 61 specified outcomes, 28 were CONSORT compliant. Specific outcome reporting issues are detailed.

Discussion: Our findings raise substantial concerns regarding these trials. Clinicians, public health professionals, and the public cannot make informed choices about the benefits or hazards of e-cigarettes if the results of clinical trials are not completely and transparently reported. Clarification and potential enforcement of reporting laws may be required.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056221DOI Listing
June 2021

Brexit and trade policy: an analysis of the governance of UK trade policy and what it means for health and social justice.

Global Health 2021 Jun 9;17(1):61. Epub 2021 Jun 9.

Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.

Background: There is an extensive body of research demonstrating that trade and globalisation can have wide-ranging implications for health. Robust governance is key to ensuring that health, social justice and sustainability are key considerations within trade policy, and that health risks from trade are effectively mitigated and benefits are maximised. The UK's departure from the EU provides a rare opportunity to examine a context where trade governance arrangements are being created anew, and to explore the consequences of governance choices and structures for health and social justice. Despite its importance to public health, there has been no systematic analysis of the implications of UK trade policy governance. We therefore conducted an analysis of the governance of the UK's trade policy from a public health and social justice perspective.

Results: Several arrangements required for good governance appear to have been implemented - information provision, public consultation, accountability to Parliament, and strengthening of civil service capacity. However, our detailed analyses of these pillars of governance identified significant weaknesses in each of these areas.

Conclusion: The establishment of a new trade policy agenda calls for robust systems of governance. However, our analysis demonstrates that, despite decades of mounting evidence on the health and equity impacts of trade and the importance of strong systems of governance, the UK government has largely ignored this evidence and failed to galvanise the opportunity to include public health and equity considerations and strengthen democratic involvement in trade policy. This underscores the point that the evidence alone will not guarantee that health and justice are prioritised. Rather, we need strong systems of governance everywhere that can help seize the health benefits of international trade and minimise its detrimental impacts. A failure to strengthen governance risks poor policy design and implementation, with unintended and inequitable distribution of harms, and 'on-paper' commitments to health, social justice, and democracy unfulfilled in practice. Although the detailed findings relate to the situation in the UK, the issues raised are, we believe, of wider relevance for those with an interest of governing for health in the area of international trade.
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http://dx.doi.org/10.1186/s12992-021-00697-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188541PMC
June 2021

What went wrong in the UK's covid-19 response?

Authors:
Martin McKee

BMJ 2021 05 24;373:n1309. Epub 2021 May 24.

London School of Hygiene and Tropical Medicine, UK

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http://dx.doi.org/10.1136/bmj.n1309DOI Listing
May 2021

Supply-side factors influencing informal payment for healthcare services in Tanzania.

Health Policy Plan 2021 May 21. Epub 2021 May 21.

Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania.

Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers' perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision.
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http://dx.doi.org/10.1093/heapol/czab034DOI Listing
May 2021

What is the right level of spending needed for health and care in the UK?

Lancet 2021 05 6;397(10288):2012-2022. Epub 2021 May 6.

Department of Health Policy, London School of Economics and Political Science, London, UK.

The health and care sector plays a valuable role in improving population health and societal wellbeing, protecting people from the financial consequences of illness, reducing health and income inequalities, and supporting economic growth. However, there is much debate regarding the appropriate level of funding for health and care in the UK. In this Health Policy paper, we look at the economic impact of the COVID-19 pandemic and historical spending in the UK and comparable countries, assess the role of private spending, and review spending projections to estimate future needs. Public spending on health has increased by 3·7% a year on average since the National Health Service (NHS) was founded in 1948 and, since then, has continued to assume a larger share of both the economy and government expenditure. In the decade before the ongoing pandemic started, the rate of growth of government spending for the health and care sector slowed. We argue that without average growth in public spending on health of at least 4% per year in real terms, there is a real risk of degradation of the NHS, reductions in coverage of benefits, increased inequalities, and increased reliance on private financing. A similar, if not higher, level of growth in public spending on social care is needed to provide high standards of care and decent terms and conditions for social care staff, alongside an immediate uplift in public spending to implement long-overdue reforms recommended by the Dilnot Commission to improve financial protection. COVID-19 has highlighted major issues in the capacity and resilience of the health and care system. We recommend an independent review to examine the precise amount of additional funds that are required to better equip the UK to withstand further acute shocks and major threats to health.
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http://dx.doi.org/10.1016/S0140-6736(21)00230-0DOI Listing
May 2021

The changing health needs of the UK population.

Lancet 2021 05 6;397(10288):1979-1991. Epub 2021 May 6.

Department of Epidemiology and Public Health, University College London, London, UK.

The demographics of the UK population are changing and so is the need for health care. In this Health Policy, we explore the current health of the population, the changing health needs, and future threats to health. Relative to other high-income countries, the UK is lagging on many health outcomes, such as life expectancy and infant mortality, and there is a growing burden of mental illness. Successes exist, such as the striking improvements in oral health, but inequalities in health persist as well. The growth of the ageing population relative to the working-age population, the rise of multimorbidity, and persistent health inequalities, particularly for preventable illness, are all issues that the National Health Service (NHS) will face in the years to come. Meeting the challenges of the future will require an increased focus on health promotion and disease prevention, involving a more concerted effort to understand and tackle the multiple social, environmental, and economic factors that lie at the heart of health inequalities. The immediate priority of the NHS will be to mitigate the wider and long-term health consequences of the COVID-19 pandemic, but it must also strengthen its resilience to reduce the impact of other threats to health, such as the UK leaving the EU, climate change, and antimicrobial resistance.
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http://dx.doi.org/10.1016/S0140-6736(21)00229-4DOI Listing
May 2021

What can lifespan variation reveal that life expectancy hides? Comparison of five high-income countries.

J R Soc Med 2021 May 6:1410768211011742. Epub 2021 May 6.

London School of Hygiene and Tropical Medicine, London, UK.

Objectives: In most countries, life expectancy at birth (e0) has improved for many decades. Recently, however, progress has stalled in the UK and Canada, and reversed in the USA. Lifespan variation, a complementary measure of mortality, increased a few years before the reversal in the USA. To assess whether this measure offers additional meaningful insights, we examine what happened in four other high-income countries with differing life expectancy trends.

Design: We calculated life disparity (a specific measure of lifespan variation) in five countries -- USA, UK, France, Japan and Canada -- using sex- and age specific mortality rates from the Human Mortality Database from 1975 to 2017 for ages 0--100 years. We then examined trends in age-specific mortality to identify the age groups contributing to these changes.

Setting: USA, UK, France, Japan and Canada.

Participants: aggregate population data of the above nations.

Main Outcome Measures: Life expectancy at birth, life disparity and age-specific mortality.

Results: The stalls and falls in life expectancy, for both males and females, seen in the UK, USA and Canada coincided with rising life disparity. These changes may be driven by worsening mortality in middle-age (such as at age 40). France and Japan, in contrast, continue on previous trajectories.

Conclusions: Life disparity is an additional summary measure of population health providing information beyond that signalled by life expectancy at birth alone.
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http://dx.doi.org/10.1177/01410768211011742DOI Listing
May 2021

Resilience Testing of Health Systems: How Can It Be Done?

Int J Environ Res Public Health 2021 04 29;18(9). Epub 2021 Apr 29.

Amsterdam UMC, Department of Public and Occupational Health, Amsterdam Public Health Research Institute, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands.

The resilience of health systems has received considerable attention as of late, yet little is known about what a resilience test might look like. We develop a resilience test concept and methodology. We describe key components of a toolkit and a 5-phased approach to implementation of resilience testing that can be adapted to individual health systems. We develop a methodology for a test that is balanced in terms of standardization and system-specific characteristics/needs. We specify how to work with diverse stakeholders from the health ecosystem via participatory processes to assess and identify recommendations for health system strengthening. The proposed resilience test toolkit consists of "what if" adverse scenarios, a menu of health system performance elements and indicators based on an input-output-outcomes framework, a discussion guide for each adverse scenario, and a traffic light scorecard template. The five phases of implementation include Phase 0, a preparatory phase to adapt the toolkit materials; Phase 1: facilitated discussion groups with stakeholders regarding the adverse scenarios; Phase 2: supplemental data collection of relevant quantitative indicators; Phase 3: summarization of results; Phase 4: action planning and health system transformation. The toolkit and 5-phased approach can support countries to test resilience of health systems, and provides a concrete roadmap to its implementation.
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http://dx.doi.org/10.3390/ijerph18094742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8124463PMC
April 2021

Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: A systematic review.

J Migr Health 2021 22;3:100041. Epub 2021 Apr 22.

Institute for Infection and Immunity, St George's University of London, London, UK.

Background: Migrants in high-income countries may be at increased risk of COVID-19 due to their health and social circumstances, yet the extent to which they are affected and their predisposing risk factors are not clearly understood. We did a systematic review to assess clinical outcomes of COVID-19 in migrant populations, indirect health and social impacts, and to determine key risk factors.

Methods: We did a systematic review following PRISMA guidelines (PROSPERO CRD42020222135). We searched multiple databases to 18/11/2020 for peer-reviewed and grey literature on migrants (foreign-born) and COVID-19 in 82 high-income countries. We used our international networks to source national datasets and grey literature. Data were extracted on primary outcomes (cases, hospitalisations, deaths) and we evaluated secondary outcomes on indirect health and social impacts and risk factors using narrative synthesis.

Results: 3016 data sources were screened with 158 from 15 countries included in the analysis (35 data sources for primary outcomes: cases [21], hospitalisations [4]; deaths [15]; 123 for secondary outcomes). We found that migrants are at increased risk of infection and are disproportionately represented among COVID-19 cases. Available datasets suggest a similarly disproportionate representation of migrants in reported COVID-19 deaths, as well as increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps have been especially affected. Migrants experience risk factors including high-risk occupations, overcrowded accommodation, and barriers to healthcare including inadequate information, language barriers, and reduced entitlement.

Conclusions: Migrants in high-income countries are at high risk of exposure to, and infection with, COVID-19. These data are of immediate relevance to national public health and policy responses to the pandemic. Robust data on testing uptake and clinical outcomes in migrants, and barriers and facilitators to COVID-19 vaccination, are urgently needed, alongside strengthening engagement with diverse migrant groups.
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http://dx.doi.org/10.1016/j.jmh.2021.100041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061095PMC
April 2021

Smoking prevalence and economic crisis in Brazil.

Rev Saude Publica 2021 2;55. Epub 2021 Apr 2.

London School of Hygiene and Tropical Medicine. London, UK.

Objective: To estimate the impact of the 2015-2018 economic crisis on tobacco consumption in Brazil.

Methods: This is an interrupted time series analysis conducted with data from 27 cities collected by VIGITEL, using linear regression models to account for first-order autocorrelation. Analyses were conducted based on gender, age group, and education level.

Results: Smoking rates decreased between 2006 and 2018, decelerating after the crisis onset. Differently than women, men showed an immediate but transient increase in smoking, followed by a decelerated decrease. Those over 65 also showed increased smoking rates immediately after the economic crisis onset, but decline accelerated later on. In turn, we found a trend reversal among those aged 31-44. Rates also decreased among those with lower education levels, but decelerated among those with more years of schooling.

Conclusion: An economic crisis have varied impacts on the smoking habits of different population groups. Tobacco control policies should entail a detailed understanding of smoking epidemiology, especially during an economic crisis.
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http://dx.doi.org/10.11606/s1518-8787.2021055002768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009317PMC
April 2021
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