Pub Date : 2024-02-01DOI: 10.1136/bmjph-2023-000209
Jan M Stratil, R. Biallas, A. Movsisyan, Kathryn Oliver, Eva Rehfuess
Despite the best intentions and intended beneficial outcomes, public health (PH) interventions can have adverse effects and other unintended consequences (AUCs). AUCs are rarely systematically examined when developing, evaluating or implementing PH interventions. We, therefore, used a multipronged, evidence-based approach to develop a framework to support researchers and decision-makers in anticipating and assessing AUCs of PH interventions.We employed the ‘best-fit’ synthesis approach, starting with an a priori framework and iteratively revising this based on systematically identified evidence. The a priori framework was designed using key elements of the WHO-INTEGRATE framework and the Behaviour Change Wheel, to root it in global health norms and values, established mechanisms of PH interventions and a complexity perspective. The a priori framework was advanced based on theoretical and conceptual publications and systematic reviews on the topic of AUCs in PH. Thematic analysis was used to revise the framework and identify new themes. To test the framework, it was coded against four systematic reviews of AUCs of PH interventions.The Cosequences of Public Health Interventions (CONSEQUENT) framework includes two components: the first focuses on AUCs and serves to categorise them; the second (supplementary) component highlights the mechanisms through which AUCs may arise. The first component comprises eight domains of consequences: health, health system, human rights, acceptability and adherence, equality, and equity, social and institutional, economic and resources, and the environment.The CONSEQUENT framework is intended to facilitate classification and conceptualisation of AUCs of PH interventions during their development or evaluation to support evidence-informed decision-making.
{"title":"Development of an overarching framework for anticipating and assessing adverse and other unintended consequences of public health interventions (CONSEQUENT): a best-fit framework synthesis","authors":"Jan M Stratil, R. Biallas, A. Movsisyan, Kathryn Oliver, Eva Rehfuess","doi":"10.1136/bmjph-2023-000209","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000209","url":null,"abstract":"Despite the best intentions and intended beneficial outcomes, public health (PH) interventions can have adverse effects and other unintended consequences (AUCs). AUCs are rarely systematically examined when developing, evaluating or implementing PH interventions. We, therefore, used a multipronged, evidence-based approach to develop a framework to support researchers and decision-makers in anticipating and assessing AUCs of PH interventions.We employed the ‘best-fit’ synthesis approach, starting with an a priori framework and iteratively revising this based on systematically identified evidence. The a priori framework was designed using key elements of the WHO-INTEGRATE framework and the Behaviour Change Wheel, to root it in global health norms and values, established mechanisms of PH interventions and a complexity perspective. The a priori framework was advanced based on theoretical and conceptual publications and systematic reviews on the topic of AUCs in PH. Thematic analysis was used to revise the framework and identify new themes. To test the framework, it was coded against four systematic reviews of AUCs of PH interventions.The Cosequences of Public Health Interventions (CONSEQUENT) framework includes two components: the first focuses on AUCs and serves to categorise them; the second (supplementary) component highlights the mechanisms through which AUCs may arise. The first component comprises eight domains of consequences: health, health system, human rights, acceptability and adherence, equality, and equity, social and institutional, economic and resources, and the environment.The CONSEQUENT framework is intended to facilitate classification and conceptualisation of AUCs of PH interventions during their development or evaluation to support evidence-informed decision-making.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140464752","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-01DOI: 10.1136/bmjph-2023-000399
Y. S. Yimer, Tariku Tesfaye, Awgichew Kifle Zemelak, Solomon Emyu Ferede
In Ethiopia, a significant proportion of women who receive antenatal care (ANC) deliver at home. This study aims to investigate home delivery among pregnant women who receive ANC during pregnancy in Ethiopia. Increased coverage of ANC is advised to improve institutional delivery, which in turn prevents maternal and neonatal morbidity and mortality.We used data from the Performance Monitoring for Action Ethiopia panel study, which followed pregnant women 1 year through post partum. A total of 1749 women who received ANC during pregnancy were included in this study. To identify risk factors associated with home delivery, a design-based binary logistic regression analysis was used.Of 1749 women who received ANC, 515 (29.4%) gave birth at home. Discussions on place of delivery with partner (adjusted OR (AOR)=0.56, 95% CI=0.35 to 0.90); desire to deliver at home (AOR=3.35, 95% CI=2.15 to 5.22); multiple birth readiness topics during ANC visits (AOR=0.39, 95% CI=0.21 to 0.63); and had ANC by a professional healthcare provider (AOR=0.40, 95% CI=0.23 to 0.70) were found to be significant predictors of home delivery.This study found that one-third of women who received ANC gave birth at home. Discussions on place of delivery with partner, birth readiness topics, women’s desire for place of delivery and type of ANC provider were found to be independent predictors. Our results indicate for special attention to the evaluation and improvement of health extension workers’ competency in ANC delivery, and counselling women on various aspects of birth readiness during ANC visits.
{"title":"Home delivery among women who receive antenatal care in Ethiopia, design-based logistic regression analysis","authors":"Y. S. Yimer, Tariku Tesfaye, Awgichew Kifle Zemelak, Solomon Emyu Ferede","doi":"10.1136/bmjph-2023-000399","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000399","url":null,"abstract":"In Ethiopia, a significant proportion of women who receive antenatal care (ANC) deliver at home. This study aims to investigate home delivery among pregnant women who receive ANC during pregnancy in Ethiopia. Increased coverage of ANC is advised to improve institutional delivery, which in turn prevents maternal and neonatal morbidity and mortality.We used data from the Performance Monitoring for Action Ethiopia panel study, which followed pregnant women 1 year through post partum. A total of 1749 women who received ANC during pregnancy were included in this study. To identify risk factors associated with home delivery, a design-based binary logistic regression analysis was used.Of 1749 women who received ANC, 515 (29.4%) gave birth at home. Discussions on place of delivery with partner (adjusted OR (AOR)=0.56, 95% CI=0.35 to 0.90); desire to deliver at home (AOR=3.35, 95% CI=2.15 to 5.22); multiple birth readiness topics during ANC visits (AOR=0.39, 95% CI=0.21 to 0.63); and had ANC by a professional healthcare provider (AOR=0.40, 95% CI=0.23 to 0.70) were found to be significant predictors of home delivery.This study found that one-third of women who received ANC gave birth at home. Discussions on place of delivery with partner, birth readiness topics, women’s desire for place of delivery and type of ANC provider were found to be independent predictors. Our results indicate for special attention to the evaluation and improvement of health extension workers’ competency in ANC delivery, and counselling women on various aspects of birth readiness during ANC visits.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140469588","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-01DOI: 10.1136/bmjph-2023-000514
F. Cavallaro, Ruth Gilbert, J. van der Meulen, Sally Kendall, Eilis Kennedy, Katie L. Harron
We evaluated the effectiveness of the Family Nurse Partnership (FNP), an intensive home visiting programme aiming to improve birth outcomes, child health and development, and to promote economic self-sufficiency among teenage mothers.We created a linked cohort of >130 000 mothers aged 13–19 years with live births between April 2010 and March 2019, using administrative data from health (Hospital Episode Statistics), education and children’s social care (National Pupil Database). Using propensity score matching, we compared indicators of child maltreatment, health and development outcomes, and maternal hospital utilisation and educational outcomes up to 7 years following birth for mothers who did or did not enrol in FNP.We found no evidence of an association between FNP and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 years for children born to FNP mothers (6.6% vs 5.7%, relative risk (RR) 1.15; 95% CI 1.07, 1.24). There was weak evidence that children born to FNP mothers were more likely to achieve a good level of development at age 5 years (57.5% vs 55.4%, RR 1.05; 95% CI 1.00, 1.09). FNP mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs 9.3%, RR 0.92; 95% CI 0.88, 0.97).Our study supports findings from previous evaluations of FNP showing no evidence of benefit for child maltreatment or health outcomes measured in administrative data. Bias by indication, and variation in the intervention and usual care, may have limited our ability to detect effects. Future evaluations should capture more information on maternal risk factors and additional outcomes relating to maternal/child well-being.
{"title":"Intensive home visiting for adolescent mothers in the Family Nurse Partnership in England 2010–2019: a population-based data linkage cohort study using propensity score matching","authors":"F. Cavallaro, Ruth Gilbert, J. van der Meulen, Sally Kendall, Eilis Kennedy, Katie L. Harron","doi":"10.1136/bmjph-2023-000514","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000514","url":null,"abstract":"We evaluated the effectiveness of the Family Nurse Partnership (FNP), an intensive home visiting programme aiming to improve birth outcomes, child health and development, and to promote economic self-sufficiency among teenage mothers.We created a linked cohort of >130 000 mothers aged 13–19 years with live births between April 2010 and March 2019, using administrative data from health (Hospital Episode Statistics), education and children’s social care (National Pupil Database). Using propensity score matching, we compared indicators of child maltreatment, health and development outcomes, and maternal hospital utilisation and educational outcomes up to 7 years following birth for mothers who did or did not enrol in FNP.We found no evidence of an association between FNP and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 years for children born to FNP mothers (6.6% vs 5.7%, relative risk (RR) 1.15; 95% CI 1.07, 1.24). There was weak evidence that children born to FNP mothers were more likely to achieve a good level of development at age 5 years (57.5% vs 55.4%, RR 1.05; 95% CI 1.00, 1.09). FNP mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs 9.3%, RR 0.92; 95% CI 0.88, 0.97).Our study supports findings from previous evaluations of FNP showing no evidence of benefit for child maltreatment or health outcomes measured in administrative data. Bias by indication, and variation in the intervention and usual care, may have limited our ability to detect effects. Future evaluations should capture more information on maternal risk factors and additional outcomes relating to maternal/child well-being.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140464893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-01-01DOI: 10.1136/bmjph-2023-000345
Monia Makhoul, H. Ayoub, S. Awad, H. Chemaitelly, L. Abu-Raddad
Chlamydia trachomatis(CT) infection is a global health challenge. New approaches are needed to control CT disease burden.An age-structured deterministic mathematical model calibrated to nationally representative population-based data was developed to investigate the impact of CT vaccination on the population of the USA if a vaccine becomes available. The model’s parameters were chosen based on current knowledge from the literature on CT’s natural history and epidemiology. The model’s calibration used age-specific CT prevalence data sourced from the biannual rounds of the National Health and Nutrition Examination Surveys. The reported data are based on the outcomes generated by the model’s simulations.Over a 10-year period, vaccinating 80% of individuals aged 15–49 with a vaccine that reduces by 50% susceptibility to infection (VES=50%), infectiousness (VEI=50%) or duration of infection (VEP=50%) resulted, respectively, in 36.3%, 26.5% and 42.1% reduction in CT prevalence, and 38.8%, 28.6% and 24.1% reduction in CT incidence rate. Number of averted infections was 11 346 000, 7 583 000 and 6 012 000, respectively. When efficacies acted together (VES=VEI=VEP=50%), CT prevalence and incidence rate were reduced by 66.3% and 61.0%, respectively. Number of vaccinations needed to avert one infection was 17.7 forVES=50%, 26.5 forVEI=50%, 33.4 forVEP=50%and 12.0 forVES=VEI=VEP=50%. Vaccinating individuals aged 15–19 and at highest risk of infection was most effective, requiring only 7.7 and 1.8 vaccinations to prevent one infection, respectively. Vaccination benefits were larger beyond 10 years.A moderately efficacious CT vaccine can significantly reduce CT disease burden. Targeting specific populations can maximise cost-effectiveness. Additional potential ‘breakthrough’ effects of the vaccine on infectiousness and duration of infection could greatly increase its impact. CT vaccine development and implementation should be a public health priority.
{"title":"Impact of a potential Chlamydia vaccine in the USA: mathematical modelling analyses","authors":"Monia Makhoul, H. Ayoub, S. Awad, H. Chemaitelly, L. Abu-Raddad","doi":"10.1136/bmjph-2023-000345","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000345","url":null,"abstract":"Chlamydia trachomatis(CT) infection is a global health challenge. New approaches are needed to control CT disease burden.An age-structured deterministic mathematical model calibrated to nationally representative population-based data was developed to investigate the impact of CT vaccination on the population of the USA if a vaccine becomes available. The model’s parameters were chosen based on current knowledge from the literature on CT’s natural history and epidemiology. The model’s calibration used age-specific CT prevalence data sourced from the biannual rounds of the National Health and Nutrition Examination Surveys. The reported data are based on the outcomes generated by the model’s simulations.Over a 10-year period, vaccinating 80% of individuals aged 15–49 with a vaccine that reduces by 50% susceptibility to infection (VES=50%), infectiousness (VEI=50%) or duration of infection (VEP=50%) resulted, respectively, in 36.3%, 26.5% and 42.1% reduction in CT prevalence, and 38.8%, 28.6% and 24.1% reduction in CT incidence rate. Number of averted infections was 11 346 000, 7 583 000 and 6 012 000, respectively. When efficacies acted together (VES=VEI=VEP=50%), CT prevalence and incidence rate were reduced by 66.3% and 61.0%, respectively. Number of vaccinations needed to avert one infection was 17.7 forVES=50%, 26.5 forVEI=50%, 33.4 forVEP=50%and 12.0 forVES=VEI=VEP=50%. Vaccinating individuals aged 15–19 and at highest risk of infection was most effective, requiring only 7.7 and 1.8 vaccinations to prevent one infection, respectively. Vaccination benefits were larger beyond 10 years.A moderately efficacious CT vaccine can significantly reduce CT disease burden. Targeting specific populations can maximise cost-effectiveness. Additional potential ‘breakthrough’ effects of the vaccine on infectiousness and duration of infection could greatly increase its impact. CT vaccine development and implementation should be a public health priority.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140516862","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1136/bmjph-2023-000559
S. Steeg, Faraz Mughal, Nav Kapur, S. Gnani, Catherine Robinson
Suicide prevention is a major public health challenge. Appropriate aftercare for self-harm is vital due to increased risks of suicide following self-harm. Many antecedents to self-harm involve social factors and there is strong rationale for social services-based self-harm aftercare. We aimed to review evidence for social service utilisation and referrals among people seeking help following self-harm.Systematic review with narrative synthesis.PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online, citation lists of included articles and grey literature.Studies of people of any age in contact with health services following self-harm, with study outcomes including referrals to or utilisation of social workers and social services.Information was extracted from each included study using a proforma and quality was critically assessed by two reviewers. Narrative synthesis was used to review the evidence.From a total of 3414 studies retrieved, 10 reports of 7 studies were included. Study quality was generally high to moderate. All studies were based in emergency departments (EDs) and most were UK based. In studies based solely on ED data, low proportions were referred to social services (in most studies, 1%–4%, though it was up to 44% when social workers were involved in ED assessments). In one study using linked data, 15% (62/427) were referred to social services and 21% (466/2,205) attended social services over the subsequent 3-year period.Overall, few patients were referred to social services after self-harm. Higher reported referral rates may reflect greater service availability, involvement of social workers in psychosocial assessments or better capture of referral activity. Social services-based and integrated approaches for self-harm aftercare are important future directions for suicide prevention. Improved links between social services and health services for people seeking support after self-harm are recommended.
预防自杀是一项重大的公共卫生挑战。由于自残后自杀的风险增加，对自残进行适当的善后护理至关重要。许多自残的前因都涉及到社会因素，基于社会服务的自残善后照顾也有很强的理论基础。我们的目的是回顾社会服务利用的证据和自残后寻求帮助的人的转介。系统回顾与叙事综合。PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online，收录文章引文列表和灰色文献。对自残后接触卫生服务的任何年龄段的人进行研究，研究结果包括转介或利用社会工作者和社会服务。从每个纳入的研究中提取信息，使用形式表，并由两名审稿人对质量进行严格评估。叙述性综合用于审查证据。从共检索到的3414项研究中，纳入了7项研究的10份报告。研究质量一般为高至中等。所有的研究都是在急诊科进行的，大多数是在英国进行的。在仅基于ED数据的研究中，涉及社会服务的比例很低(在大多数研究中，这一比例为1%-4%，尽管当社会工作者参与ED评估时，这一比例高达44%)。在一项使用关联数据的研究中，15%(62/427)的人被转到社会服务机构，21%(466/ 2205)的人在随后的3年里参加了社会服务。总体而言，很少有患者在自残后被转介到社会服务机构。较高的转诊率报告可能反映了更多的服务可获得性，社会工作者参与心理社会评估或更好地捕捉转诊活动。以社会服务为基础的综合自残善后护理是未来预防自杀的重要方向。建议为自残后寻求支持的人改善社会服务和保健服务之间的联系。
{"title":"Social services utilisation and referrals after seeking help from health services for self-harm: a systematic review and narrative synthesis","authors":"S. Steeg, Faraz Mughal, Nav Kapur, S. Gnani, Catherine Robinson","doi":"10.1136/bmjph-2023-000559","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000559","url":null,"abstract":"Suicide prevention is a major public health challenge. Appropriate aftercare for self-harm is vital due to increased risks of suicide following self-harm. Many antecedents to self-harm involve social factors and there is strong rationale for social services-based self-harm aftercare. We aimed to review evidence for social service utilisation and referrals among people seeking help following self-harm.Systematic review with narrative synthesis.PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online, citation lists of included articles and grey literature.Studies of people of any age in contact with health services following self-harm, with study outcomes including referrals to or utilisation of social workers and social services.Information was extracted from each included study using a proforma and quality was critically assessed by two reviewers. Narrative synthesis was used to review the evidence.From a total of 3414 studies retrieved, 10 reports of 7 studies were included. Study quality was generally high to moderate. All studies were based in emergency departments (EDs) and most were UK based. In studies based solely on ED data, low proportions were referred to social services (in most studies, 1%–4%, though it was up to 44% when social workers were involved in ED assessments). In one study using linked data, 15% (62/427) were referred to social services and 21% (466/2,205) attended social services over the subsequent 3-year period.Overall, few patients were referred to social services after self-harm. Higher reported referral rates may reflect greater service availability, involvement of social workers in psychosocial assessments or better capture of referral activity. Social services-based and integrated approaches for self-harm aftercare are important future directions for suicide prevention. Improved links between social services and health services for people seeking support after self-harm are recommended.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138625941","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1136/bmjph-2023-000191
I. Grant, Neil Chalmers, E. Fletcher, F. Lakha, Gerry McCartney, D. Stockton, Grant M. A. Wyper
Health inequalities in Scotland are well documented, including the contribution of different causes to inequalities in mortality. Our aim was to estimate inequalities within a burden of disease framework, accounting for both premature mortality and the effects of morbidity, to understand the contribution of specific diseases to health inequalities prior to the COVID-19 pandemic.Disability-adjusted life-years (DALYs) for 70 individual causes of disease and injury were sourced from the Scottish Burden of Disease Study. Area-level deprivation was measured using the Scottish Index of Multiple Deprivation. Inequalities were measured by the range, Relative Index of Inequality, Slope Index of Inequality and attributable DALYs were estimated by using the least deprived decile as a reference.The overall disease burden was double that in the most deprived areas (50 305 vs 20 955 DALYS per 100 000), largely driven by inequalities in premature mortality. The rate in the most deprived areas was around 48% higher than the mean population rate (Relative Index of Inequality=0.96), with 35% of DALYs attributed to differences in area-based deprivation. Many leading causes of disease burden in 2019—heart disease, drug use disorders, lung cancer and chronic obstructive pulmonary disease—were also the leading drivers of absolute and relative inequalities in the disease burden.Our study evidences the extent of the stark levels of absolute and relative inequality prior to the COVID-19 pandemic. Given prepandemic stalling of mortality trend improvements and widening health inequalities, and the exacerbation of these caused by COVID-19, urgent policy attention is required to address this.
{"title":"Prepandemic inequalities in the burden of disease in Scotland due to multiple deprivation: a retrospective study","authors":"I. Grant, Neil Chalmers, E. Fletcher, F. Lakha, Gerry McCartney, D. Stockton, Grant M. A. Wyper","doi":"10.1136/bmjph-2023-000191","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000191","url":null,"abstract":"Health inequalities in Scotland are well documented, including the contribution of different causes to inequalities in mortality. Our aim was to estimate inequalities within a burden of disease framework, accounting for both premature mortality and the effects of morbidity, to understand the contribution of specific diseases to health inequalities prior to the COVID-19 pandemic.Disability-adjusted life-years (DALYs) for 70 individual causes of disease and injury were sourced from the Scottish Burden of Disease Study. Area-level deprivation was measured using the Scottish Index of Multiple Deprivation. Inequalities were measured by the range, Relative Index of Inequality, Slope Index of Inequality and attributable DALYs were estimated by using the least deprived decile as a reference.The overall disease burden was double that in the most deprived areas (50 305 vs 20 955 DALYS per 100 000), largely driven by inequalities in premature mortality. The rate in the most deprived areas was around 48% higher than the mean population rate (Relative Index of Inequality=0.96), with 35% of DALYs attributed to differences in area-based deprivation. Many leading causes of disease burden in 2019—heart disease, drug use disorders, lung cancer and chronic obstructive pulmonary disease—were also the leading drivers of absolute and relative inequalities in the disease burden.Our study evidences the extent of the stark levels of absolute and relative inequality prior to the COVID-19 pandemic. Given prepandemic stalling of mortality trend improvements and widening health inequalities, and the exacerbation of these caused by COVID-19, urgent policy attention is required to address this.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138621592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1136/bmjph-2023-000316
Angel Walker, C. Abnet, M.S. Shiels, Wayne R. Lawrence, Tanya Funchess, Deirdre B Rogers, Monica Webb Hooper, Yingxi Chen
Oesophageal cancer is one of the most aggressive cancers. The aim was to describe the disparities in oesophageal cancer incidence and mortality, and county-level factors in the state of Mississippi from 2003 to 2019 by sex, race, and geolocation.This study used data from the Mississippi Cancer Registry, linked to county-level data from the Behavioral Risk Factor Surveillance System, the American Community Survey, and the Institutes for Health Metrics and Evaluation. We estimated age-standardised incidence (crude ASR) and mortality rates (crude AMR), mortality–incidence rate ratio and average annual percent change (AAPC) in rates by sex, race, and geolocation, using the Joinpoint Software V.5.0. We further calculated relative risks for oesophageal cancer using age-adjusted quasi-Poisson regression for each county-level factor including smoking, obesity, college degree completion, unemployment rate and median household income ranking within the state.Between 2003 and 2019, a total of 2737 oesophageal cancer cases and 2259 oesophageal cancer deaths occurred in Mississippi. Black men had the greatest reduction in oesophageal cancer incidence and mortality despite high rates (crude ASR2019=10.5, crude AMR2019=7.3 per 100 000; AAPCincidence=−3.7%, p<0.001 and AAPCmortality=−4.9%, p<0.001). The reduction was largely driven by decreases in the non-Delta region (AAPCincidence=−4.2%, p<0.001), while incidence rate remained high among Black men in the Delta region (crude ASR2019=15.4 per 100 000, AAPCincidence=−1.8%, p=0.3). The rates among White men were relatively stable (crude ASR2019=8.5, crude AMR2019=7.6 per 100 000; AAPCincidence=0.18%, p=0.7, AAPCmortality=−0.4%, p=0.6). County-level smoking prevalence (in quartile, p=0.02) was significantly associated with oesophageal cancer incidence.This study highlights the importance of targeted interventions to address the persistent high incidence rate of oesophageal cancer among Black men in the Delta region.
{"title":"Racial and geographical disparities in oesophageal cancer incidence, mortality and county-level risk factors in the state of Mississippi between 2003 and 2019: a descriptive analysis","authors":"Angel Walker, C. Abnet, M.S. Shiels, Wayne R. Lawrence, Tanya Funchess, Deirdre B Rogers, Monica Webb Hooper, Yingxi Chen","doi":"10.1136/bmjph-2023-000316","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000316","url":null,"abstract":"Oesophageal cancer is one of the most aggressive cancers. The aim was to describe the disparities in oesophageal cancer incidence and mortality, and county-level factors in the state of Mississippi from 2003 to 2019 by sex, race, and geolocation.This study used data from the Mississippi Cancer Registry, linked to county-level data from the Behavioral Risk Factor Surveillance System, the American Community Survey, and the Institutes for Health Metrics and Evaluation. We estimated age-standardised incidence (crude ASR) and mortality rates (crude AMR), mortality–incidence rate ratio and average annual percent change (AAPC) in rates by sex, race, and geolocation, using the Joinpoint Software V.5.0. We further calculated relative risks for oesophageal cancer using age-adjusted quasi-Poisson regression for each county-level factor including smoking, obesity, college degree completion, unemployment rate and median household income ranking within the state.Between 2003 and 2019, a total of 2737 oesophageal cancer cases and 2259 oesophageal cancer deaths occurred in Mississippi. Black men had the greatest reduction in oesophageal cancer incidence and mortality despite high rates (crude ASR2019=10.5, crude AMR2019=7.3 per 100 000; AAPCincidence=−3.7%, p<0.001 and AAPCmortality=−4.9%, p<0.001). The reduction was largely driven by decreases in the non-Delta region (AAPCincidence=−4.2%, p<0.001), while incidence rate remained high among Black men in the Delta region (crude ASR2019=15.4 per 100 000, AAPCincidence=−1.8%, p=0.3). The rates among White men were relatively stable (crude ASR2019=8.5, crude AMR2019=7.6 per 100 000; AAPCincidence=0.18%, p=0.7, AAPCmortality=−0.4%, p=0.6). County-level smoking prevalence (in quartile, p=0.02) was significantly associated with oesophageal cancer incidence.This study highlights the importance of targeted interventions to address the persistent high incidence rate of oesophageal cancer among Black men in the Delta region.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138625378","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1136/bmjph-2023-000421
T. Holmager, G. Napolitano, Neda Esmailzadeh Bruun-Rasmussen, R. Jepsen, Søren Lophaven, Elsebeth Lynge
Lolland-Falster is the area of Denmark with highest mortality. However, clinical measurements from a population-based health survey showed prevalence of disease indicators similar to those in the rest of Denmark. The study aimed to disentangle this paradox.The Lolland-Falster Health Study (LOFUS) took place in 2016–2020. We followed the 53 000 invited persons up for mortality from invitation date to 1 February 2023. Log-binomial regression was used to calculate relative risk (RR) of non-participation versus participation in LOFUS by subgroups of sex, age, municipality, residency group, household composition and economic status. Using Poisson regression, mortality rate ratio (MRR) was calculated between subgroups and within subgroups for non-participants versus participants for all-cause mortality and mortality from cancer, cardiovascular diseases, respiratory diseases, external causes and other diseases.One-third (36%) of persons invited to LOFUS participated. Only modest differences were seen in participation across subgroups; the largest being an RR of 1.37 (95% CI 1.35 to 1.40) for publicly supported versus self-supported persons. However, non-participants had higher mortality than participants (MRR 3.08, 95% CI 2.82 to 3.37). This pattern was consistent across all subgroups and was found for both all-cause and cause-specific mortality.The paradox we observed could partly be attributed to participation differences between subgroups. However, for the lack of population representativeness of the survey data, our study indicated within-group selection, measured by excess mortality of non-participants, to be much more important than between-group selection. One should therefore be cautious in using even weighted health survey data for prioritising health interventions.
洛兰-法尔斯特是丹麦死亡率最高的地区。然而，一项基于人群的健康调查的临床测量结果显示，该地区的疾病患病率指标与丹麦其他地区相似。这项研究旨在解开这一悖论。Lolland-Falster健康研究(LOFUS)于2016-2020年进行。从邀请之日起至2023年2月1日，我们对53,000名受邀者的死亡率进行了随访。采用对数二项回归，按性别、年龄、城市、居住群体、家庭组成和经济状况等亚组计算不参加与参加LOFUS的相对风险(RR)。使用泊松回归，计算了非参与者与参与者的全因死亡率以及癌症、心血管疾病、呼吸系统疾病、外因和其他疾病的死亡率在亚组之间和亚组内的死亡率比(MRR)。三分之一(36%)被邀请参加联卢特派团的人参加了会议。亚组之间的参与程度差异不大;其中最大的是公共供养者与自食自力者的RR为1.37 (95% CI 1.35至1.40)。然而，非参与者的死亡率高于参与者(MRR 3.08, 95% CI 2.82至3.37)。这种模式在所有亚组中都是一致的，并且在全因死亡率和特定原因死亡率中都发现了这种模式。我们观察到的这种矛盾可以部分归因于子群体之间的参与差异。然而，由于调查数据缺乏人口代表性，我们的研究表明，通过非参与者的超额死亡率来衡量的组内选择比组间选择重要得多。因此，在使用加权卫生调查数据确定卫生干预措施的优先次序时应谨慎。
{"title":"Health and participation in the Lolland-Falster Health Study: a cohort study","authors":"T. Holmager, G. Napolitano, Neda Esmailzadeh Bruun-Rasmussen, R. Jepsen, Søren Lophaven, Elsebeth Lynge","doi":"10.1136/bmjph-2023-000421","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000421","url":null,"abstract":"Lolland-Falster is the area of Denmark with highest mortality. However, clinical measurements from a population-based health survey showed prevalence of disease indicators similar to those in the rest of Denmark. The study aimed to disentangle this paradox.The Lolland-Falster Health Study (LOFUS) took place in 2016–2020. We followed the 53 000 invited persons up for mortality from invitation date to 1 February 2023. Log-binomial regression was used to calculate relative risk (RR) of non-participation versus participation in LOFUS by subgroups of sex, age, municipality, residency group, household composition and economic status. Using Poisson regression, mortality rate ratio (MRR) was calculated between subgroups and within subgroups for non-participants versus participants for all-cause mortality and mortality from cancer, cardiovascular diseases, respiratory diseases, external causes and other diseases.One-third (36%) of persons invited to LOFUS participated. Only modest differences were seen in participation across subgroups; the largest being an RR of 1.37 (95% CI 1.35 to 1.40) for publicly supported versus self-supported persons. However, non-participants had higher mortality than participants (MRR 3.08, 95% CI 2.82 to 3.37). This pattern was consistent across all subgroups and was found for both all-cause and cause-specific mortality.The paradox we observed could partly be attributed to participation differences between subgroups. However, for the lack of population representativeness of the survey data, our study indicated within-group selection, measured by excess mortality of non-participants, to be much more important than between-group selection. One should therefore be cautious in using even weighted health survey data for prioritising health interventions.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138625746","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1136/bmjph-2023-000482
O. Esan, A. Adeomi, O. Afolabi
Inequitable financial access to maternal healthcare services (MHS) has contributed to maternal deaths, especially in low and middle-income countries. Evidence in the literature on women’s health insurance status and access to MHS in Nigeria is sparse. This study aimed to determine the association between health insurance coverage and access to MHS among Nigerian women of reproductive age.This is a cross-sectional study that used the 2018 Nigeria Demographic and Health Survey (NDHS). A total of 12 935 women who had their last delivery within 2 years before the NDHS were included in the study. Access to MHS was assessed by using the number of antenatal care (ANC) visits and health facility delivery. Adjusted logistic regression models were fit to control for individual, household and community-level factors.Only 18.5% and 40.6% of the women in the study attended ≥8 ANC visits and delivered in a health facility, respectively. About 39.5% of women who had ≥8 ANC visits and 71.8% of those who delivered in health facilities had health insurance coverage. There were statistically significant associations between having health insurance and attendance of ≥8 ANC visits (adjusted OR (AOR) 1.9; 95% CI 1.26–2.95) and women delivering at a health facility (AOR 2.0; 95% CI 1.39–2.82). There were also lower significant odds of accessing ≥8 ANC visits and delivering in health facilities among the rural dwellers, unemployed, those with lower educational status and those in the lower social economic quintiles.There was a low uptake of health insurance programmes among the Nigerian women in this study. Having health insurance coverage was significantly associated with ≥8 ANC visits and women delivering in health facilities. Thus, providing health insurance may be an important way to improve women’s access to MHS in Nigeria.
孕产妇保健服务(MHS)的资金获取不公平导致孕产妇死亡，特别是在低收入和中等收入国家。文献中关于尼日利亚妇女健康保险状况和获得妇幼保健服务的证据很少。本研究旨在确定尼日利亚育龄妇女健康保险覆盖率与获得保健服务之间的关系。这是一项横断面研究，使用了2018年尼日利亚人口与健康调查(NDHS)。共有12935名在国家人口健康调查前2年内最后一次分娩的妇女被纳入研究。通过使用产前保健(ANC)访问次数和保健设施交付次数来评估获得妇幼保健服务的情况。调整后的logistic回归模型适合控制个体、家庭和社区层面的因素。在这项研究中，分别只有18.5%和40.6%的妇女参加了≥8次产前检查并在卫生机构分娩。约39.5%接受过≥8次产前检查的妇女和71.8%在卫生设施分娩的妇女享有医疗保险。有健康保险与≥8次ANC就诊之间存在统计学显著关联(调整OR (AOR) 1.9;95%可信区间1.26-2.95)和在卫生机构分娩的妇女(AOR 2.0;95% ci 1.39-2.82)。在农村居民、失业者、教育程度较低的人和社会经济水平较低的五分之一人群中，获得≥8次ANC就诊和在卫生设施分娩的几率也较低。在这项研究中，尼日利亚妇女对医疗保险方案的接受程度较低。拥有健康保险与≥8次ANC就诊和妇女在卫生机构分娩显著相关。因此，提供医疗保险可能是改善尼日利亚妇女获得妇幼保健服务的一个重要途径。
{"title":"Health insurance coverage and access to maternal healthcare services by women of reproductive age in Nigeria: a cross-sectional study","authors":"O. Esan, A. Adeomi, O. Afolabi","doi":"10.1136/bmjph-2023-000482","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000482","url":null,"abstract":"Inequitable financial access to maternal healthcare services (MHS) has contributed to maternal deaths, especially in low and middle-income countries. Evidence in the literature on women’s health insurance status and access to MHS in Nigeria is sparse. This study aimed to determine the association between health insurance coverage and access to MHS among Nigerian women of reproductive age.This is a cross-sectional study that used the 2018 Nigeria Demographic and Health Survey (NDHS). A total of 12 935 women who had their last delivery within 2 years before the NDHS were included in the study. Access to MHS was assessed by using the number of antenatal care (ANC) visits and health facility delivery. Adjusted logistic regression models were fit to control for individual, household and community-level factors.Only 18.5% and 40.6% of the women in the study attended ≥8 ANC visits and delivered in a health facility, respectively. About 39.5% of women who had ≥8 ANC visits and 71.8% of those who delivered in health facilities had health insurance coverage. There were statistically significant associations between having health insurance and attendance of ≥8 ANC visits (adjusted OR (AOR) 1.9; 95% CI 1.26–2.95) and women delivering at a health facility (AOR 2.0; 95% CI 1.39–2.82). There were also lower significant odds of accessing ≥8 ANC visits and delivering in health facilities among the rural dwellers, unemployed, those with lower educational status and those in the lower social economic quintiles.There was a low uptake of health insurance programmes among the Nigerian women in this study. Having health insurance coverage was significantly associated with ≥8 ANC visits and women delivering in health facilities. Thus, providing health insurance may be an important way to improve women’s access to MHS in Nigeria.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138615147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-12-01DOI: 10.1136/bmjph-2023-000563
B. Pham, Tess Aga, Rebecca Emori, Doris Manong, S. Maraga, Billiam Degemba, Vicky Gabe, Noel Berry, Michael Kobol, Lydia Kue, Nanim Ainui, Ronny Jorry, Vinson D Silas, Norah Abori, Gasowo S Jaukae, Guise Gende, Toan H Ha, A. Okely, William Pomat
The COVID-19 pandemic had an unprecedented impact on the health and well-being of populations worldwide. Few studies have used household data to explore the health risks associated with COVID-19 in low-income and middle-income countries. This study assessed population vulnerability to COVID-19 by examining household socioeconomic factors related to COVID-19 health risks in Papua New Guinea (PNG).Using household socioeconomic surveillance data from 2020, encompassing 37 880 residents living within the catchment areas of the Comprehensive Health and Epidemiological Surveillance System, the study assessed COVID-19 health risks based on the socioeconomic demographic characteristics of the surveillance population. Multinomial logistic regression analyses were conducted to determine associated factors and to estimate predictors of COVID-19 health risks.Among the surveillance population, more than 9% reported experiencing COVID-19 health risks, including home-based quarantine (9.6%), centre-based quarantine (0.5%), positive COVID-19 test (0.1%), hospitalisation due to COVID-19 (0.3%) and death from COVID-19 (0.3%). People living in semimodern houses (OR 1.47 (95% CI 1.35 to 1.61)) (verse permanent houses), individuals living in houses with 1–2 bedrooms (OR 1.12 (95% CI 1.01 to 1.25)) (verse houses with 4+ bedrooms) and those belonging to the poorest wealth quintile (OR 1.16 (95% CI 1.024 to 1.314)) (verse the richest) were more susceptible to COVID-19 health risks. Protective factors against COVID-19 health risks included urban residence (OR 0.65 (95% CI 0.59 to 0.71)) (verse rurality), aged 0–4 years (OR 0.76 (95% CI 0.64 to 0.91)) (verse aged 55+ years), households with 7–8 members (OR 0.84 (95% CI 0.74 to 0.96)) (verse 10+ members), handwashing with soap (OR 0.3 (95% CI 0.28 to 0.33)) (verse without soap).The study provides insights into the susceptibility to COVID-19 health risks across socioeconomic groups in PNG. These findings have implications for development of public health policies and interventions that can be extrapolated to similar settings for enhancing preparedness for future public health emergencies.
2019冠状病毒病大流行对全世界人民的健康和福祉产生了前所未有的影响。在低收入和中等收入国家，很少有研究使用家庭数据来探索与COVID-19相关的健康风险。本研究通过检查巴布亚新几内亚与COVID-19健康风险相关的家庭社会经济因素，评估了人口对COVID-19的脆弱性。该研究利用2020年以来的家庭社会经济监测数据，包括生活在健康和流行病学综合监测系统集水区的37880名居民，根据监测人群的社会经济人口统计学特征评估了COVID-19的健康风险。进行多项逻辑回归分析以确定相关因素并估计COVID-19健康风险的预测因子。在监测人群中，超过9%的人报告存在COVID-19健康风险，包括家庭隔离(9.6%)、中心隔离(0.5%)、COVID-19检测阳性(0.1%)、因COVID-19住院(0.3%)和因COVID-19死亡(0.3%)。居住在半现代房屋(OR 1.47 (95% CI 1.35至1.61))(相对于永久性房屋)、居住在1-2间卧室房屋(OR 1.12 (95% CI 1.01至1.25))(相对于4间以上卧室的房屋)和属于最贫穷财富五分之一(OR 1.16 (95% CI 1.024至1.314))(相对于最富有的房屋)的人更容易受到COVID-19健康风险的影响。预防COVID-19健康风险的保护因素包括城市居住(OR 0.65 (95% CI 0.59至0.71))(农村)、0-4岁(OR 0.76 (95% CI 0.64至0.91))(55岁以上)、7-8人家庭(OR 0.84 (95% CI 0.74至0.96))(10人以上)、用肥皂洗手(OR 0.3 (95% CI 0.28至0.33))(不使用肥皂)。该研究为巴布亚新几内亚社会经济群体对COVID-19健康风险的易感性提供了见解。这些发现对公共卫生政策和干预措施的制定具有启示意义，这些政策和干预措施可以外推到类似的环境中，以加强对未来突发公共卫生事件的防范。
{"title":"Assessing health impact of COVID-19 and associated household socioeconomic factors in Papua New Guinea: evidence from the Comprehensive Health and Epidemiological Surveillance System","authors":"B. Pham, Tess Aga, Rebecca Emori, Doris Manong, S. Maraga, Billiam Degemba, Vicky Gabe, Noel Berry, Michael Kobol, Lydia Kue, Nanim Ainui, Ronny Jorry, Vinson D Silas, Norah Abori, Gasowo S Jaukae, Guise Gende, Toan H Ha, A. Okely, William Pomat","doi":"10.1136/bmjph-2023-000563","DOIUrl":"https://doi.org/10.1136/bmjph-2023-000563","url":null,"abstract":"The COVID-19 pandemic had an unprecedented impact on the health and well-being of populations worldwide. Few studies have used household data to explore the health risks associated with COVID-19 in low-income and middle-income countries. This study assessed population vulnerability to COVID-19 by examining household socioeconomic factors related to COVID-19 health risks in Papua New Guinea (PNG).Using household socioeconomic surveillance data from 2020, encompassing 37 880 residents living within the catchment areas of the Comprehensive Health and Epidemiological Surveillance System, the study assessed COVID-19 health risks based on the socioeconomic demographic characteristics of the surveillance population. Multinomial logistic regression analyses were conducted to determine associated factors and to estimate predictors of COVID-19 health risks.Among the surveillance population, more than 9% reported experiencing COVID-19 health risks, including home-based quarantine (9.6%), centre-based quarantine (0.5%), positive COVID-19 test (0.1%), hospitalisation due to COVID-19 (0.3%) and death from COVID-19 (0.3%). People living in semimodern houses (OR 1.47 (95% CI 1.35 to 1.61)) (verse permanent houses), individuals living in houses with 1–2 bedrooms (OR 1.12 (95% CI 1.01 to 1.25)) (verse houses with 4+ bedrooms) and those belonging to the poorest wealth quintile (OR 1.16 (95% CI 1.024 to 1.314)) (verse the richest) were more susceptible to COVID-19 health risks. Protective factors against COVID-19 health risks included urban residence (OR 0.65 (95% CI 0.59 to 0.71)) (verse rurality), aged 0–4 years (OR 0.76 (95% CI 0.64 to 0.91)) (verse aged 55+ years), households with 7–8 members (OR 0.84 (95% CI 0.74 to 0.96)) (verse 10+ members), handwashing with soap (OR 0.3 (95% CI 0.28 to 0.33)) (verse without soap).The study provides insights into the susceptibility to COVID-19 health risks across socioeconomic groups in PNG. These findings have implications for development of public health policies and interventions that can be extrapolated to similar settings for enhancing preparedness for future public health emergencies.","PeriodicalId":117861,"journal":{"name":"BMJ Public Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138611196","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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