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In August 2020 the UK government announced without warning the abolition of Public Health England (PHE), the principal UK agency for the promotion and protection of public health. We undertook a research programme seeking to understand the factors surrounding this decision. While the underlying issues are complex two competing interpretations have emerged: an ‘official’ explanation, which highlights the failure of PHE to scale up its testing capacity in the early weeks of the COVID-19 pandemic as the fundamental reason for closing it down and a ‘sceptical’ interpretation, which ascribes the decision to blame-avoidance behaviour on the part of leading government figures. This paper reviews crucial claims in these two competing explanations exploring the arguments for and against each proposition. It concludes that neither is adequate and that the inability adequately to address the problem of testing (which triggered the decision to close PHE) lies deeper in the absence of the norms of responsible government in UK politics and the state. However our findings do provide some guidance to the two new organizations established to replace PHE to maximize their impact on public health. We hope that this information will contribute to the independent national COVID inquiry.
Hand hygiene is a simple, low-cost intervention that may lead to substantial population-level effects in suppressing acute respiratory infection epidemics. However, quantification of the efficacy of hand hygiene on respiratory infection in the community is lacking. We searched PubMed for randomised controlled trials on the effect of hand hygiene for reducing acute respiratory infections in the community published before 11 March 2021. We performed a meta-regression analysis using a Bayesian mixed-effects model. A total of 105 publications were identified, out of which six studies reported hand hygiene frequencies. Four studies were performed in household settings and two were in schools. The average number of handwashing events per day ranged from one to eight in the control arms, and four to 17 in the intervention arms. We estimated that a single hand hygiene event is associated with a 3% (80% credible interval (−1% to 7%)) decrease in the daily probability of an acute respiratory infection. Three of these six studies were potentially at high risk of bias because the primary outcome depended on self-reporting of upper respiratory tract symptoms. Well-designed trials with an emphasis on monitoring hand hygiene adherence are needed to confirm these findings.
To characterize the association between the protracted biopsychosocial coronavirus disease 2019 (COVID-19) pandemic exposures and incident suicide attempt rates.
Data were from a nationally representative cohort based on electronic health records from January 2013 to February 2021 (N = 852 233), with an interrupted time series study design. For the primary analysis, the effect of COVID-19 pandemic on incident suicide attempts warranting in-patient hospital treatment was quantified by fitting a Poisson regression and modeling the relative risk (RR) and the corresponding 95% confidence intervals (CIs). Scenarios were forecast to predict attempted suicide rates at 10 months after social mitigation strategies. Fourteen sensitivity analyses were performed to test the robustness of the results.
Despite the increasing trend in the unexposed interval, the interval exposed to the COVID-19 pandemic was statistically significant (p < 0.001) associated with a reduced RR of incident attempted suicide (RR = 0.63, 95% CI 0.52–0.78). Consistent with the primary analysis, sensitivity analysis of sociodemographic groups and methodological factors were statistically significant (p < 0.05). No effect modification was identified for COVID-19 lockdown intervals or COVID-19 illness status. All three forecast scenarios at 10 months projected a suicide attempt rate increase from 12.49 (7.42–21.01) to 21.38 (12.71–35.99).
The interval exposed to the protracted mass social trauma of the COVID-19 pandemic was associated with a lower suicide attempt rate compared to the unexposed interval. However, this trend is likely to reverse 10 months after lifting social mitigation policies, underscoring the need for enhanced implementation of public health policy for suicide prevention.
The aim of this study was to explore and analyse the actions implemented by civil society to contribute to food security in the context of the COVID-19 outbreak in Uruguay, a high-income country in South America.
An exploratory systematic approach was used to identify the contributions of civil society to food security through reports in news websites and Facebook posts. Data were analysed based on content analysis following a deductive–inductive approach.
Uruguay, Latin America.
A total of 1220 civil society organisations were identified, which developed two main actions to increase access to food among the Uruguayan population: food baskets and ‘community pots’ (also known as ‘common pots’). Most of the initiatives targeted citizens under socioeconomic vulnerability in the face of COVID-19, without specifying any specific requirement or population segment. Actions were mainly led by spontaneously organised community groups, and, to a lesser extent, by consolidated organisations. Interactions between organisations were identified. The foods provided by the organisations were mostly aligned with national dietary guidelines. Social media posts evidenced that the main challenge faced by organisations was related to the lack of funds or supplies.
Results from this work suggest that the lack of funds or supplies poses challenges to the medium- and long-term contributions of civil society to food security and stresses the need for comprehensive governmental measures to guarantee food security amongst Uruguayan citizens.
In 2015, beverages were removed from display at a self-service café within a major health service, resulting in fewer purchases of unhealthy beverages. This initiative was continued following initial evaluation of the results. The current study aimed to determine customer acceptability of the initiative, and whether healthier purchases had continued, at 18 months following implementation.
Drinks were categorised as ‘green’ (best choices), ‘amber’ (choose carefully) and ‘red’ (limit), based on the state government nutrient profiling system, for intervention and analysis purposes. In 2015, unhealthy ‘red’ drinks were removed from display. In 2017, weekly beverage sales were counted, through stock-taking, for 6 weeks, and customer surveys were conducted over 2 days.
A café located within a major Victorian health service.
Café customers (hospital staff, patients and visitors).
Eighteen months after the implementation of the initiative, the proportion of ‘red’ beverages sold was 7 % of total drink sales (compared with 33 % before the removal of unhealthy beverages from display in 2015 (P < 0·001), and 10 % immediately following the removal of unhealthy beverages from display). Customer surveys revealed high levels of acceptability for the initiative and low levels of awareness of the initiative.
The removal of unhealthy beverages from display can result in customers making healthier purchases, and this appears to continue over the long-term. Such interventions have the potential to contribute to the sustained shift in population purchases and consumption needed to make meaningful improvements to population health.
The deliberate use of chemical, biological, radiological, and nuclear (CBRN) materials in war or terrorist attacks is perceived as a great threat globally. In the event of a release of CBRN agents, protection by means of medical countermeasures (MedCMs) could reduce health vulnerability. Nonetheless, for some diseases caused by these agents, innovative MedCMs do not exist and many of those that do might not be readily available. Inappropriate research and development funding and government procurement efforts can result in adverse economic consequences (eg, lost income, cost per loss of life, medical expenses) far exceeding the costs of strong and comprehensive preparedness initiatives. By illustrating factors of demand-side rationale for CBRN MedCMs, this article aims to strengthen integrity of policy-making associated with current demand requirements. Namely, an approach to inspire broader assessment is outlined by compiling and adapting existing economic models and concepts to characterize both soft and hard factors that influence demand-side rationale. First, the soft factor context is set by describing the impact of behavioral and political economics. Then, lessons learned from past public health funding models and associated collaborative access infrastructure are depicted to represent hard factors that can enhance the viability of MedCM preparedness evaluations.
To assess the consumption of sugar-sweetened beverages (SSB) and other energy-dense nutrient-poor (EDNP) foods in two Southern low-income communities targeted by the Balance Calories Initiative, a campaign by the top-three American beverage companies intended to reduce the consumption of sugary beverages by 20 % over 10 years.
We conducted self-administered intercept surveys in front of food retail outlets between August and November 2016. We recruited adults with children <18 years living at home and adolescents aged 10–17 years with parental consent.
Retail food outlets in Mississippi and Alabama, USA.
Adults (n 11 311) and adolescents (n 3460).
The percentage of high SSB consumers (≥4 servings/d) was 40·9 % among adult males, 32·3 % among adult females, 43·0 % among adolescent males and 34·4 % among adolescent females (male – female difference, P < 0·0001). In aggregate, respondents also reported consuming a mean of 3 servings of salty snacks, cookies and/or candy in the past 24 h, with adolescent males reporting 4 servings.
SSB should be a primary target of future interventions to improve dietary intake, but EDNP foods likely contribute as many daily kilojoules as SSB among this population. Future campaigns should aim to limit the consumption of all EDNP foods.
In politically contested health debates, stakeholders on both sides present arguments and evidence to influence public opinion and the political agenda. The present study aimed to examine whether stakeholders in the Soft Drinks Industry Levy (SDIL) debate sought to establish or undermine the acceptability of this policy through the news media and how this compared with similar policy debates in relation to tobacco and alcohol industries.
Quantitative and qualitative content analysis of newspaper articles discussing sugar-sweetened beverage (SSB) taxation published in eleven UK newspapers between 1 April 2015 and 30 November 2016, identified through the Nexis database. Direct stakeholder citations were entered in NVivo to allow inductive thematic analysis and comparison with an established typology of industry stakeholder arguments used by the alcohol and tobacco industries.
Proponents and opponents of SSB tax/SDIL cited in UK newspapers.
Four hundred and ninety-one newspaper articles cited stakeholders’ (n 287) arguments in relation to SSB taxation (n 1761: 65 % supportive and 35 % opposing). Stakeholders’ positions broadly reflected their vested interests. Inconsistencies arose from: changes in ideological position; insufficient clarity on the nature of the problem to be solved; policy priorities; and consistency with academic rigour. Both opposing and supportive themes were comparable with the alcohol and tobacco industry typology.
Public health advocates were particularly prominent in the UK newspaper debate surrounding the SDIL. Advocates in future policy debates might benefit from seeking a similar level of prominence and avoiding inconsistencies by being clearer about the policy objective and mechanisms.
Latin American countries are taking important steps to expand and strengthen universal health coverage, and health technology assessment (HTA) has an increasingly prominent role in this process. Participation of all relevant stakeholders has become a priority in this effort. Key issues in this area were discussed during the 2017 Latin American Health Technology Assessment International (HTAi) Policy Forum.
The Forum included forty-one participants from Latin American HTA agencies; public, social security, and private insurance sectors; and the pharmaceutical and medical device industry. A background paper and presentations by invited experts and Forum members supported discussions. This study presents a summary of these discussions.
Stakeholder involvement in HTA remains inconsistently implemented in the region and few countries have established formal processes. Participants agreed that stakeholder involvement is key to improve the HTA process, but the form and timing of such improvements must be adapted to local contexts. The legitimization of both HTA and decision-making processes was identified as one of the main reasons to promote stakeholder involvement; but to be successful, the entire system of assessment and decision making must be properly staffed and organized, and certain basic conditions must be met, including transparency in the HTA process and a clear link between HTA and decision making.
Participants suggested a need for establishing clear rules of participation in HTA that would protect HTA producers and decision makers from potentially distorting external influences. Such rules and mechanisms could help foster trust and credibility among stakeholders, supporting actual involvement in HTA processes.
The aim of this study was to identify good practice principles for health technology assessment (HTA) that are the most relevant and of highest priority for application in Latin America and to identify potential barriers to their implementation in the region.
HTA good practice principles proposed at the international level were identified and then explored during a deliberative process in a forum of assessors, funders, and product manufacturers.
Forty-two representatives from ten Latin American countries participated. Good practice principles proposed at the international level were considered valid and potentially relevant to Latin America. Five principles were identified as priority and with the greatest potential to be strengthened at this time: transparency in the production of HTA, involvement of relevant stakeholders in the HTA process, mechanisms to appeal decisions, clear priority-setting processes in HTA, and a clear link between HTA and decision making. The main challenge identified was to find a balance between the application of these principles and the available resources in a way that would not detract from the production of reports and adaptation to the needs of decision makers.
The main recommendation was to progress gradually in strengthening HTA and its link to decision making by developing appropriate processes for each country, without trying to impose, in the short-term, standards taken from examples at the international level without adequate adaptation of these to local contexts.
We estimated the number of people unaware of their human immunodeficiency virus (HIV) infection in our province, Pavia (population 540 000) in Lombardy, Italy, by means of anonymous unlinked testing of 10 044 serum/plasma samples residual from clinical analyses at the outpatient clinic of Policlinico San Matteo in 2014 and 2015. Ethical and legal approval was obtained prior to study start. Samples were irreversibly anonymised, only retaining gender and 5-year age class. Five sample pools were tested for HIV using LIAISON® XL MUREX HIV Ab/Ag (DiaSorin, Saluggia, Italy). If the pool tested positive, individual samples underwent confirmatory tests, Innotest HIV Antigen mAb (Fujirebio Europe, Gent, Belgium) and HIV BLOT 2·2 (MP Diagnostics, Singapore). Among the 10 044 samples processed, eight were confirmed positive (0·08%, 95% confidence interval 0·03–0·16%), all were males and age was >50 in 3 (37·5%). If projected to the entire population of the Pavia province, this would result in approximately 1000 people unaware of their HIV infection, with age older than expected. In Italy, HIV testing is voluntary, universally free-of-charge and (upon request) anonymous. Nevertheless, this study demonstrates that it is suboptimally employed, and that new strategies and population-level actions will be needed to achieve better implementation of HIV testing and HIV control in our province.
The present study assessed the impact of the retailer-led removal of unhealthy beverages from display at a self-service café within a major health service. While unhealthy beverages remained available from behind the counter upon request, this was not communicated directly to customers.
Drinks were categorised based on the state government nutrient profiling system, classifying drinks as ‘green’ (best choices), ‘amber’ (choose carefully) and ‘red’ (limit). Total drink sales (as number of items sold per week) in the café were measured for five weeks. All unhealthy ‘red’ beverages were removed from display (but were still available for purchase) and the sales of all beverages were measured for another six weeks.
We found that, in response to this strategy, the proportion of ‘red’ drinks sold decreased from 33 % to 10 % of total drink sales. As ‘amber’ and ‘green’ drink sales increased in response to this strategy, total retailer sales remained steady. Most consumers appeared to switch to purchasing ‘amber’ drinks rather than the healthiest option, ‘green’ drinks.
The removal of unhealthy beverages from display can result in consumers making healthier purchases, while not significantly affecting retailers’ sales.
To compare the energy, nutrient and food group compositions of three sources of school-day lunches among students in five secondary schools in the Republic of Ireland (ROI).
Cross-sectional study conducted between October 2012 and March 2013. Students completed self-report food diaries over two school days. The energy, nutrient, nutrient density and food group composition of school-day lunches from home, school and ‘out’ in local food outlets were compared using ANCOVA and Tukey’s Honest Significant Difference post hoc analysis.
Five secondary schools in the ROI.
Male and female students aged 15–17 years (n 305).
Six hundred and fifteen lunches (376 home lunches, 115 school lunches and 124 lunches sourced ‘out’ in the local environment) were analysed. School and ‘out’ purchased lunches were significantly higher than packed lunches from home in energy (2047 kJ (489 kcal), 2664 kJ (627 kcal), 1671 kJ (399 kcal), respectively), total fat (23·5 g, 30·1 g, 16·6 g, respectively) and free (added) sugars (12·6 g, 19·3 g, 7·4 g, respectively). More home lunches contained more fruit, wholemeal breads, cheese and red meat than lunches from school or ‘out’. Meat products, chips and high-calorie beverages were sourced more frequently at school or ‘out’ than home. Fibre and micronutrient contents of lunches from all sources were low.
Home-sourced lunches had the healthiest nutritional profile in terms of energy and macronutrients. Foods high in energy, fat and free sugars associated with school and local food outlets are of concern given the public health focus to reduce their consumption. While school food should be improved, all sources of lunches need to be considered when addressing the dietary behaviours of secondary-school students.
To evaluate measles incidence and its relevant changes over a 14-year period (2000–2014), we analysed data from the regional hospital discharge database on children and adults hospitalized in Tuscany, Italy. A total of 181 paediatric and 413 adult cases were identified. Despite all the efforts towards regional measles elimination, we observed that the overall measles hospitalization rates for children and adults living in Tuscany globally increased from 0·45 to 0·85/100 000 during the study period (P = 0·001) showing fluctuations due to periodic measles outbreaks. Data stratified by age group showed that the hospitalization rate significantly increased in young adults over the study period, confirming an increase in susceptibility to measles in this subpopulation. Conversely, no statistically significant difference was observed in the hospitalization rate in the other age groups. However, children aged <1 year still exhibit the highest hospitalization rate. Pneumonia represented the most common complication in both the adult and children subsets. No death was reported. Measles still represents a public health problem, and national strategies should be implemented, focusing on emergent susceptible subsets, such as infants and young adults.
This article sets out to investigate the political development and implementation of parenting support services in Sweden. The object of the analysis is on how parenting support has been organised and how it has been articulated in policy debates, and also key elements of parenting support in practice. The analysis shows that parenting support builds upon a century-long tradition of, for example, pre-emptive health care check-ups and services to parents, counselling and parenting education. There are, however, elements in parenting support policy which mark a clear deviation from this policy legacy. These include the introduction of structured parenting programmes, the growth of the idea of parents as autonomous beings, and the partial relocation of parenting support into new public health goals.
(i) To map how US adults value ‘choice’ in the context of obesity policy and (ii) to discuss implications for obesity prevention in children.
Semi-structured interviews (n 105) were conducted between 2006 and 2009 about causes of and solutions to childhood obesity. Quotes captured in field notes from community meetings (n 6) on childhood obesity prevention were also analysed. Each use of the word ‘choice’ and its variants was identified in these texts. Content and discourse were analysed to identify the implied values and meaning in each use.
One hundred and five adults, some involved in childhood obesity prevention initiatives.
Three distinct frames of ‘choice’ emerged: (i) having choices (choice as freedom), (ii) making choices (choice as responsibility) and (iii) influencing choices (contextual constraints and impacts on choice). Many speakers used more than one frame over the course of an interview. Most people using the third frame seemed to share the values behind the first two frames, but focused on conditions required to enable people to be accountable for their choices and to make truly free choices. A small subset thought outside the frame of individual choice, valuing, as one person put it, a ‘social contract’.
Public debate in the USA about responsibility for and solutions to rising obesity rates often hinges on notions of ‘choice’. These frames, and the values underlying them, are not mutually exclusive. Respecting the values behind each ‘choice’ frame when crafting obesity prevention policy and employing all three in public communications about such policy may facilitate greater consensus on prevention measures.
The present study aimed to evaluate the nutritional status of pregnant women in Colombia and the associations between gestational BMI and sociodemographic and gestational characteristics.
Cross-sectional study. A secondary analysis was made of data from the 2005 Demographic and Health Survey of Colombia.
Pregnant adolescents aged 13–19 years (n 430) and pregnant women aged 20–49 years (n 1272).
The gestational BMI and sociodemographic characteristics of the adolescents differed from those of the pregnant adult women. Thirty-one per cent of the adolescents were underweight for gestational age, compared with 14·5 % of the adult women. Eighteen per cent of adolescents were overweight for gestational age, in contrast to 37·3 % of adult women. The overall prevalence of anaemia was 44·7 % and the prevalence of low serum ferritin was 38·8 %. Women within the high quintiles of the wealth index (prevalence odds ratio (POR) = 0·56; 95 % CI 0·34, 0·91, P < 0·02) had lower odds of being underweight. Women who received prenatal care (POR = 2·17; 95 % CI 1·48, 3·09, P < 0·001) and were multiparous (POR = 2·10; 95 % CI 1·43, 3·15, P < 0·0 0 1) had higher odds of being overweight. Women in extended families (POR = 0·63; 95 % CI 0·50, 0·95, P < 0·025) had lower odds of being overweight.
Underweight in pregnant adolescents and overweight in adult women coexist as a double burden in Colombia. Factors associated with malnutrition among pregnant women and adolescents should be considered for future interventions in countries experiencing nutritional transition.
Early childhood growth retardation persists in developing countries despite decades of nutritional interventions. Adequate food is necessary, but not sufficient, to ensure normal growth where there is ubiquitous exposure to infection. Pathways associated with infection, small intestinal mucosal damage and chronic immunostimulation remain largely undemonstrated in countries other than The Gambia. We conducted a longitudinal study of one squatter and one middle-class group (n 86, 3–18 month olds) to assess these relationships in Nepal. Growth, mucosal damage index (MDI; urinary lactose:creatinine ratio adjusted for body weight), morbidity reports, and blood concentrations of albumin, α-1-acid glycoprotein, IgG and Hb, were recorded monthly. Growth status worsened dramatically from 6 to 18 months, with squatters more stunted (height-for-age Z-score (HAZ), P < 0·001) and underweight (weight-for-age Z-score (WAZ), P = 0·009) than middle class. IgG increased with age, was elevated in squatter children, and negatively related to WAZ (P = 0·034). MDI showed significant negative associations with growth performance, explaining 9 and 19 % of height and weight deficits (ΔHAZ, P = 0·004; ΔWAZ, P < 0·001). Unexpectedly, these associations were weaker in squatter children, namely in the group which showed poorer growth, elevated morbidity, greater pathogen exposure (IgG) and higher MDI (P < 0·001). In Nepal, as in The Gambia, children exhibit poor growth, mucosal damage and immunostimulation. The relative impact of pathways associated with infection and undernutrition may, however, differ across socio-economic groups: in poorer children, the impact of mucosal damage and immunostimulation could be masked by nutritional constraints. This has important implications for public health interventions.
1.A new Nutrition Committee for the European Union
1.1 A new Nutrition Committee for the European Union, should be created to give independent scientific and policy advice on nutrition, diets and physical activity to the Commission. This should be supported by a strengthened Nutritional Unit within the Commission.
2.1 There needs to be a comprehensive and coherent nutritional policy for the EU
2.2 The development of European dietary goals should continue after the completion of the Eurodiet Project.
2.3 The European Commission should revise its Recommended Daily Allowances for vitamins and minerals using a systematic, evidence-based approach. Recommended Daily Allowances should be set at a level which would prevent deficiencies and lower the risk of disease.
2.4 The European Commission should produce, preferably every four years, a report on the state of nutrition, diet and physical activity in the EU. This report should contain proposals for action
3.Components of a nutrition policy
3.1 The European Commission should not be involved in the direct delivery of lifestyle advice to the public.
3.2 The European Commission should continue to support networks whose members are involved in educating the public and in training professionals about nutrition, diets and physical activity.Research
3.3 European Community funding of health-related research should better reflect the Community's public health priorities.
3.4 The European Community should ear-mark funds for large, multi-centre studies into nutrition, diet and physical activity with a duration of up to 10 years.
3.5 The European Commission should draw up proposals for the regulation of health claims.
3.6 The European Community should agree rules for the use of nutrition claims along the lines agreed by the Codex Alimentarius Commission.
3.7 The European Commission should review the 1990 Nutrition Labelling Directive particularly with a view to making nutrition labelling more comprehensible and it should encourage the development of other ways of providing consumers with information about the nutrient content of foods though, for example, the Internet.
3.8 The European Commission should review the Novel Food Regulations, particularly with a view to ensuring that the nutritional consequences of consuming novel foods are better assessed and to making approval procedures more efficient.
3.9 European Community rules on food fortification and on food supplements should be harmonised but in such a way that the interests of consumers are paramount.
3.10 The Common Agriculture Policy should be subject to a regular and systematic health impact assessment.
3.11 Given that there are subsidies under the Common Agricultural Policy designed to increase consumption of surplus food, these should be directed towards promoting the consumption of foods for which there is strong evidence of a need for increased consumption in the EU for health reasons.
Fruit and vegetable consumption
3.12 The promotion of increased fruit and vegetable consumption across the EU should be a key aspect of the European Union's proposed nutrition policy.
3.13 The European Union should review its policy on breast feeding including assessing and, if necessary, improving its legislation on breast milk substitutes and maternity leave.
3.14 The European Union should have a policy for promoting physical activity in Europe. This should be part of, or at least closely integrated with, the European Union's proposed nutritional policy.
Health targets describe government intentions for improving population health. The present paper determines whether the targets which twelve developed countries have set for obesity match the seriousness of the public health problem.
Policy documents on general public health, obesity, nutrition and physical activity were obtained by repeated searches of government websites. Details of all relevant targets on overweight, obesity, nutrition and physical activity were extracted.
Only four of the countries studied have set targets for specific reductions in the prevalence of obesity. Two have targets that only mention reducing the prevalence of obesity and two other countries wish to halt the rise in prevalence. Two countries currently have targets which are much less ambitious than those in previous policies. No obesity targets are stated in the policies of four countries. Many of the countries studied have set detailed nutrition targets, but these seldom identify desired changes in dietary behaviour. No country has set targets for a reduction in energy intake. The physical activity targets reflect recommendations from the 1990s. Few targets are set for health knowledge or behavioural intentions which are prerequisites for desired lifestyle changes.
Most of the countries studied have either set no targets or set very modest targets for reducing the prevalence of obesity. Many countries have physical activity targets that are likely to be insufficient to prevent obesity. Governments need to reconsider targets on obesity and to develop shorter-term targets which monitor desired lifestyle changes.