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Aim: To evaluate an intervention (a film and electronic leaflet) disseminated via text message by general practices to promote COVID-19 preventative behaviours in Black and South Asian communities., Methods: We carried out a before-and-after questionnaire study of attitudes to and implementation of COVID-19 preventative behaviours, and qualitative interviews about the intervention, with people registered with 26 general practices in England who identified as Black or South Asian., Results: In the 108 people who completed both questionnaires, we found no significant change in attitudes to and implementation of COVID-19 preventative behaviours, although power was too low to detect significant effects. A key qualitative finding was that participants felt they did not 'belong' to the group targeted by the intervention., Conclusion: Interventions targeting ethnic minorities in the UK need to acknowledge the heterogeneity of experience and circumstances of the target group so that people feel that the intervention is relevant to them., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Aftab Ala reports financial support was provided by Royal Surrey NHS Foundation Trust. Aftab Ala is an Associate Editor of Clinical Medicine. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2025. Published by Elsevier Ltd. All rights reserved.)

Objectives: To identify COVID-19 infectious disease models that accounted for social determinants of health (SDH)., Methods: We searched MEDLINE, EMBASE, Cochrane Library, medRxiv, and the Web of Science from December 2019 to August 2020. We included mathematical modelling studies focused on humans investigating COVID-19 impact and including at least one SDH. We abstracted study characteristics (e.g., country, model type, social determinants of health) and appraised study quality using best practices guidelines., Results: 83 studies were included. Most pertained to multiple countries (n = 15), the United States (n = 12), or China (n = 7). Most models were compartmental (n = 45) and agent-based (n = 7). Age was the most incorporated SDH (n = 74), followed by gender (n = 15), race/ethnicity (n = 7) and remote/rural location (n = 6). Most models reflected the dynamic nature of infectious disease spread (n = 51, 61%) but few reported on internal (n = 10, 12%) or external (n = 31, 37%) model validation., Conclusion: Few models published early in the pandemic accounted for SDH other than age. Neglect of SDH in mathematical models of disease spread may result in foregone opportunities to understand differential impacts of the pandemic and to assess targeted interventions., Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020207706], PROSPERO, CRD42020207706., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 John-Baptiste, Moulin, Li, Hamilton, Crichlow, Klein, Alemu, Ghattas, McDonald, Asaria, Sharpe, Pandya, Moqueet, Champredon, Moghadas, Cooper, Pinto, Stranges, Haworth-Brockman, Galvani and Ali.)

Background: Infectious disease (ID) models have been the backbone of policy decisions during the COVID-19 pandemic. However, models often overlook variation in disease risk, health burden, and policy impact across social groups. Nonetheless, social determinants are becoming increasingly recognized as fundamental to the success of control strategies overall and to the mitigation of disparities., Methods: To underscore the importance of considering social heterogeneity in epidemiological modeling, we systematically reviewed ID modeling guidelines to identify reasons and recommendations for incorporating social determinants of health into models in relation to the conceptualization, implementation, and interpretations of models., Results: After identifying 1,372 citations, we found 19 guidelines, of which 14 directly referenced at least 1 social determinant. Age ( n  = 11), sex and gender ( n  = 5), and socioeconomic status ( n  = 5) were the most commonly discussed social determinants. Specific recommendations were identified to consider social determinants to 1) improve the predictive accuracy of models, 2) understand heterogeneity of disease burden and policy impact, 3) contextualize decision making, 4) address inequalities, and 5) assess implementation challenges., Conclusion: This study can support modelers and policy makers in taking into account social heterogeneity, to consider the distributional impact of infectious disease outbreaks across social groups as well as to tailor approaches to improve equitable access to prevention, diagnostics, and therapeutics., Highlights: Infectious disease (ID) models often overlook the role of social determinants of health (SDH) in understanding variation in disease risk, health burden, and policy impact across social groups.In this study, we systematically review ID guidelines and identify key areas to consider SDH in relation to the conceptualization, implementation, and interpretations of models.We identify specific recommendations to consider SDH to improve model accuracy, understand heterogeneity, estimate policy impact, address inequalities, and assess implementation challenges., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the Gordon and Betty Moore Foundation through Grant GBMF9634 to Johns Hopkins University to support the work of the Society for Medical Decision Making (SMDM) COVID-19 Decision Modeling Initiative (CDMI). The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Muslims in the UK experienced a much larger decline in mental health than the rest of the population during the pandemic and this decline persisted even as mental health in the rest of the population bounced back to pre-pandemic levels. We use panel data from the UK Household Longitudinal Study (UKHLS) to decompose the mental health gap between Muslims and non-Muslims into those attributable to differences between the characteristics of the two groups and find that these differences - particularly Muslims being younger and being substantially overrepresented at the bottom of the income distribution - explain a substantial proportion of this gap. However, over a third of the Muslim-non-Muslim mental health gap remains unexplained by these factors and is driven by the experiences of Muslims who are neither young nor poor suggesting that this may be a result of discrimination experienced by the community. We conclude that being Muslim, being young, and being poor all independently contributed to experiencing a mental health gap and to the persistence of this gap., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The 'One Health' (OH) approach is the most promising idea in realising the global goal of eliminating canine-mediated human rabies by 2030. However, taking an OH approach to rabies elimination can mean many different things to different people. We conducted a systematic review scrutinizing economic evaluations (EEs) retrieved from MEDLINE OVID, Embase OVID, Global Health OVID, CINAHL EBSCO and ECONLIT EBSCO that used the OH approach with the intent of identifying cost-effective sets of interventions that can be combined to implement an optimal OH-based rabies elimination program and highlight key gaps in the knowledge base. Our review suggests that an optimal OH program to tackle rabies should incorporate mass dog vaccination and integrated bite case management in combination with efficient use of post-exposure prophylaxis along with a shift to a 1-week abbreviated intradermal rabies vaccine regimen in humans. We recommend that future EEs of OH interventions for rabies elimination should be performed alongside implementation research to ensure proposed interventions are feasible and adopt a wider societal perspective taking into account costs and outcomes across both the human health and animal welfare sectors. The systematic review has been registered with PROSPERO., (© The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Objectives: The pandemic and public health response to contain the virus had impacts on many aspects of young people's lives including disruptions to daily routines, opportunities for social, academic, recreational engagement and early employment. Consequently, children, adolescents and young adults may have experienced mental health challenges that required use of mental health services. This study compared rates of use for inpatient and outpatient mental health services during the pandemic to pre-pandemic rates., Design: Population-based repeated cross-sectional study., Setting: Publicly delivered mental healthcare in primary and secondary settings within the province of Ontario, Canada., Participants: All children 6-12 years of age (n=2 043 977), adolescents 13-17 years (n=1 708 754) and young adults 18-24 years (n=2 286 544), living in Ontario and eligible for provincial health insurance between March 2016 and November 2021., Primary Outcome Measures: Outpatient mental health visits to family physicians and psychiatrists for: mood and anxiety disorders, alcohol and substance abuse disorders, other non-psychotic mental health disorders and social problems. Inpatient mental health visits to emergency departments and hospitalisations for: substance-related and addictive disorders, anxiety disorders, assault-related injuries, deliberate self-harm and eating disorders. All outcomes were analysed by cohort and sex., Results: During the pandemic, observed outpatient visit rates were higher among young adults by 19.01% (95% CI: 15.56% to 22.37%; 209 vs 175 per 1000) and adolescent women 24.17% (95% CI: 18.93% to 29.15%; 131 vs 105 per 1000) for mood and anxiety disorders and remained higher than expected. Female adolescents had higher than expected usage of inpatient care for deliberate self-harm, eating disorders and assault-related injuries., Conclusions: Study results raise concerns over prolonged high rates of mental health use during the pandemic, particularly in female adolescents and young women, and highlights the need to better monitor and identify mental health outcomes associated with COVID-19 containment measures and to develop policies to address these concerns., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Living in an area with high levels of child poverty predisposes children to poorer mental and physical health. ActEarly is a 5-year research programme that comprises a large number of interventions (>20) with citizen science and co-production embedded. It aims to improve the health and well-being of children and families living in two areas of the UK with high levels of deprivation; Bradford in West Yorkshire, and the London Borough of Tower Hamlets. This protocol outlines the meta-evaluation (an evaluation of evaluations) of the ActEarly programme from a systems perspective, where individual interventions are viewed as events in the wider policy system across the two geographical areas. It includes investigating the programme's impact on early life health and well-being outcomes, interdisciplinary prevention research collaboration and capacity building, and local and national decision making., Methods: The ActEarly meta-evaluation will follow and adapt the five iterative stages of the 'Evaluation of Programmes in Complex Adaptive Systems' (ENCOMPASS) framework for evaluation of public health programmes in complex adaptive systems. Theory-based and mixed-methods approaches will be used to investigate the fidelity of the ActEarly research programme, and whether, why and how ActEarly contributes to changes in the policy system, and whether alternative explanations can be ruled out. Ripple effects and systems mapping will be used to explore the relationships between interventions and their outcomes, and the degree to which the ActEarly programme encouraged interdisciplinary and prevention research collaboration as intended. A computer simulation model ("LifeSim") will also be used to evaluate the scale of the potential long-term benefits of cross-sectoral action to tackle the financial, educational and health disadvantages faced by children in Bradford and Tower Hamlets. Together, these approaches will be used to evaluate ActEarly's dynamic programme outputs at different system levels and measure the programme's system changes on early life health and well-being., Discussion: This meta-evaluation protocol presents our plans for using and adapting the ENCOMPASS framework to evaluate the system-wide impact of the early life health and well-being programme, ActEarly. Due to the collaborative and non-linear nature of the work, we reserve the option to change and query some of our evaluation choices based on the feedback we receive from stakeholders to ensure that our evaluation remains relevant and fit for purpose., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Mansukoski et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

We study individual aversion to health and income inequality in three European countries (the United Kingdom, Germany, and Italy), its determinants and especially, the effects of exposure to three types of COVID-19 specific shocks affecting individuals' employment status, their income and health. Next, using evidence of representative samples of the population in the UK, we compare levels of health- and income-inequality aversion in the UK between the years 2016 and 2020. We document evidence of a significant increase in inequality aversion in both income and health domains. However, we show that inequality aversion is higher in the income domain than in the health domain. Furthermore, we find that inequality aversion in both domains increases in age and education and decreases in income and risk appetite. However, people directly exposed to major health shocks during the COVID-19 pandemic generally exhibited lower levels of aversion to both income and health inequality. Finally, we show that inequality aversion was significantly higher among those exposed to higher risk of COVID-19 mortality who experienced major health shocks during the pandemic., Supplementary Information: The online version contains supplementary material available at 10.1007/s00355-023-01460-8., (© The Author(s) 2023.)

Introduction: Culturally appropriate interventions to promote COVID-19 health protective measures among Black and South Asian communities in the UK are needed. We aim to carry out a preliminary evaluation of an intervention to reduce risk of COVID-19 comprising a short film and electronic leaflet., Methods and Analysis: This mixed methods study comprises (1) a focus group to understand how people from the relevant communities interpret and understand the intervention's messages, (2) a before-and-after questionnaire study examining the extent to which the intervention changes intentions and confidence to carry out COVID-19 protective behaviours and (3) a further qualitative study exploring the views of Black and South Asian people of the intervention and the experiences of health professionals offering the intervention. Participants will be recruited through general practices. Data collection will be carried out in the community., Ethics and Dissemination: The study received Health Research Authority approval in June 2021 (Research Ethics Committee Reference 21/LO/0452). All participants provided informed consent. As well as publishing the findings in peer-reviewed journals, we will disseminate the findings through the UK Health Security Agency, NHS England and the Office for Health Improvement and Disparities and ensure culturally appropriate messaging for participants and other members of the target groups., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Disadvantage in early childhood (ages 0-5 years) is associated with worse health and educational outcomes in adolescence. Evidence on the clustering of these adverse outcomes by household income is scarce in the generation of adolescents born since the turn of the millennium. We aimed to describe the association between household income in early childhood and physical health, psychological distress, smoking behaviour, obesity, and educational outcomes at age 17 years, including the patterning and clustering of these five outcomes by income quintiles., Methods: In this population-based, retrospective cohort study, we used data from the Millennium Cohort Study in which individuals born in the UK between Sept 1, 2000, and Jan 1, 2002, were followed up. We collected data on five adverse health and social outcomes in adolescents aged 17 years known to limit life chances: psychological distress, self-assessed ill health, smoking, obesity, and poor educational achievement. We compared how single and multiple outcomes were distributed across early childhood quintile groups of income, as an indicator of disadvantage, and modelled the potential effect of three income-shifting scenarios in early childhood for reducing adverse outcomes in adolescence., Findings: We included 15 245 adolescents aged 17 years, 7788 (51·1%) of whom were male and 7457 (48·9%) of whom were female. Adolescents in the lowest income quintile group in childhood were 12·7 (95% CI 6·4-25·1) times more likely than those in the highest quintile group to have four or five adverse adolescent outcomes, with poor educational achievement (risk ratio [RR] 4·6, 95% CI 4·2-5·0) and smoking (3·6, 3·0-4·2), showing the largest single risk ratios. Shifting up to the second lowest, middle, and highest income groups would reduce multiple adolescent adversities by 4·9% (95% CI -23·8 to 33·6), 32·3% (-2·7 to 67·3), and 83·9% (47·2 to 120·7), respectively. Adjusting for parental education and single parent status moderately attenuated these estimates., Interpretation: Early childhood disadvantage is more strongly correlated with multiple adolescent adversities than any of the five single adverse outcomes. However, shifting children from the lowest income quintile group to the next lowest group is ineffective. Tackling multiple adolescent adversities requires managing early childhood disadvantage across the social gradient, with income redistribution as a central element of coordinated cross-sectoral action., Funding: UK Prevention Research Partnership., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licence. Published by Elsevier Ltd.. All rights reserved.)

Background: While several scoring systems for the severity of anaphylactic reactions have been developed, there is a lack of consensus on definition and categorisation of severity of food allergy disease as a whole., Aim: To develop an international consensus on the severity of food allergy (DEfinition of Food Allergy Severity, DEFASE) scoring system, to be used globally., Methods Phase 1: We conducted a mixed-method systematic review (SR) of 11 databases for published and unpublished literature on severity of food allergy management and set up a panel of international experts., Phase 2: Based on our findings in Phase 1, we drafted statements for a two-round modified electronic Delphi (e-Delphi) survey. A purposefully selected multidisciplinary international expert panel on food allergy (n = 60) was identified and sent a structured questionnaire, including a set of statements on different domains of food allergy severity related to symptoms, health-related quality of life, and economic impact. Participants were asked to score their agreement on each statement on a 5-point Likert scale ranging from "strongly agree" to "strongly disagree". Median scores and percentage agreements were calculated. Consensus was defined a priori as being achieved if 70% or more of panel members rated a statement as "strongly agree" to "agree" after the second round. Based on feedback, 2 additional online voting rounds were conducted., Results: We received responses from 92% of Delphi panel members in round 1 and 85% in round 2. Consensus was achieved on the overall score and in all of the 5 specific key domains as essential components of the DEFASE score., Conclusions: The DEFASE score is the first comprehensive grading of food allergy severity that considers not only the severity of a single reaction, but the whole disease spectrum. An international consensus has been achieved regarding a scoring system for food allergy disease. It offers an evaluation grid, which may help to rate the severity of food allergy. Phase 3 will involve validating the scoring system in research settings, and implementing it in clinical practice., (© 2023 The Authors.)

Background: London has outperformed smaller towns and rural areas in terms of life expectancy increase. Our aim was to investigate life expectancy change at very-small-area level, and its relationship with house prices and their change., Methods: We performed a hyper-resolution spatiotemporal analysis from 2002 to 2019 for 4835 London Lower-layer Super Output Areas (LSOAs). We used population and death counts in a Bayesian hierarchical model to estimate age- and sex-specific death rates for each LSOA, converted to life expectancy at birth using life table methods. We used data from the Land Registry via the real estate website Rightmove (www.rightmove.co.uk), with information on property size, type and land tenure in a hierarchical model to estimate house prices at LSOA level. We used linear regressions to summarise how much life expectancy changed in relation to the combination of house prices in 2002 and their change from 2002 to 2019. We calculated the correlation between change in price and change in sociodemographic characteristics of the resident population of LSOAs and population turnover., Findings: In 134 (2.8%) of London's LSOAs for women and 32 (0.7%) for men, life expectancy may have declined from 2002 to 2019, with a posterior probability of a decline >80% in 41 (0.8%, women) and 14 (0.3%, men) LSOAs. The life expectancy increase in other LSOAs ranged from <2 years in 537 (11.1%) LSOAs for women and 214 (4.4%) for men to >10 years in 220 (4.6%) for women and 211 (4.4%) for men. The 2.5th-97.5th-percentile life expectancy difference across LSOAs increased from 11.1 (10.7-11.5) years in 2002 to 19.1 (18.4-19.7) years for women in 2019, and from 11.6 (11.3-12.0) years to 17.2 (16.7-17.8) years for men. In the 20% (men) and 30% (women) of LSOAs where house prices had been lowest in 2002, mainly in east and outer west London, life expectancy increased only in proportion to the rise in house prices. In contrast, in the 30% (men) and 60% (women) most expensive LSOAs in 2002, life expectancy increased solely independently of price change. Except for the 20% of LSOAs that had been most expensive in 2002, LSOAs with larger house price increases experienced larger growth in their population, especially among people of working ages (30-69 years), had a larger share of households who had not lived there in 2002, and improved their rankings in education, poverty and employment., Interpretation: Large gains in area life expectancy in London occurred either where house prices were already high, or in areas where house prices grew the most. In the latter group, the increases in life expectancy may be driven, in part, by changing population demographics., Funding: Wellcome Trust; UKRI (MRC); Imperial College London; National Institutes of Health Research., Competing Interests: JP-S is vice-chair of the Royal Society for Public Health and a partner at Lane Clark & Peacock, and reports personal fees from Novo Nordisk, all outside the submitted work. YD is a member of the Advisory Council for the King's Fund. All other authors declare no competing interests., (© 2023 The Authors.)

Early trials of novel vaccines against tuberculosis (TB) in adults have suggested substantial protection against TB. However, little is known about the feasibility and affordability of rolling out such vaccines in practice. We conducted expert interviews to identify plausible vaccination implementation strategies for the novel M72/AS01 E vaccine candidate. The strategies were defined in terms of target population, coverage, vaccination schedule and delivery mode. We modelled these strategies to estimate long-term resource requirements and health benefits arising from vaccination over 2025-2050. We presented these to experts who excluded strategies that were deemed infeasible, and estimated cost-effectiveness and budget impact for each remaining strategy. The four strategies modelled combined target populations: either everyone aged 18-50, or all adults living with HIV, with delivery strategies: either a mass campaign followed by routine vaccination of 18-year olds, or two mass campaigns 10 years apart. Delivering two mass campaigns to all 18-50-year olds was found to be the most cost-effective strategy conferring the greatest net health benefit of 1.2 million DALYs averted having a probability of being cost-effective of 65-70%. This strategy required 38 million vaccine courses to be delivered at a cost of USD 507 million, reducing TB-related costs by USD 184 million while increasing ART costs by USD 79 million. A suitably designed adult TB vaccination programme built around novel TB vaccines is likely to be cost-effective and affordable given the resource and budget constraints in South Africa., (© 2022. The Author(s).)

Background: Forty years from the seminal work of Welsh GP Julian Tudor Hart on the Inverse Care Law, inequalities in health and healthcare remain deeply embedded in Wales. There is a wider gap (over 17 years) in healthy life expectancy between people living in the most and least deprived neighborhoods in Wales. This health inequality is reflected in additional healthcare use. In this study we estimate the cost of inequality associated with this additional healthcare use to the publicly funded National Health Service (NHS) in Wales., Methods: We retrieved administrative data on all NHS inpatient admissions, outpatient and accident and emergency attendances in Wales between April 2018 and March 2019 from Digital Health and Care Wales (DHCW). Hospital service use data were translated to costs using Healthcare Resource Group (HRG) and health service specific unit cost data and linked with area level mid-year population and deprivation indices in order to calculate the healthcare costs associated with socioeconomics deprivation., Results: Inequality in healthcare use between people from more and less deprived neighborhoods was associated with an additional cost of £322 million per year to the NHS in Wales, accounting for 8.7% of total NHS hospital expenditure in the country. Emergency inpatient admissions made up by far the largest component of this additional cost contributing £247.4 million, 77% of the total. There are also substantial costs of inequality for A&E attendances and outpatient visits, though not maternity services. Elective admissions overall have a negative cost of inequality, since among men aged 50-75 and women aged 60-70, elective utilization is actually negatively associated with deprivation., Conclusion: There are wide inequalities in health and healthcare use between people living in more deprived neighborhoods and those living in less deprived neighborhoods in Wales. Tackling health inequality through a combination of health promotion and early intervention policies targeted toward deprived communities could yield substantial improvement in health and wellbeing, as well as savings for the Welsh NHS through reduced use of emergency hospital care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kadel, Allen, Darlington, Masters, Collins, Charles, Asaria, Dyakova, Bellis and Cookson.)

Objectives: This study aims to assess the trade-offs between vulnerability and efficiency attributes of contact tracing programmes based on preferences of COVID-19 contact tracing practitioners, researchers and other relevant stakeholders at the global level. Methods: We conducted an online discrete choice experiment (DCE). Respondents were recruited globally to explore preferences according to country income level and the prevailing epidemiology of COVID-19 in the local setting. The DCE attributes represented efficiency (timeliness, completeness, number of contacts), vulnerability (vulnerable population), cooperation and privacy. A mixed-logit model and latent class analysis were used. Results: The number of respondents was 181. Timeliness was the most important attribute regardless of country income level and COVID-19 epidemiological condition. Vulnerability of contacts was the second most important attribute for low-to-lower-middle-income countries and third for upper-middle-to-high income countries. When normalised against conditional relative importance of timeliness, conditional relative importance of vulnerability ranged from 0.38 to 0.42. Conclusion: Vulnerability and efficiency criteria were both considered to be important attributes of contact tracing programmes. However, the relative values placed on these criteria varied significantly between epidemiological and economic context., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Wang, Faradiba, Del Rio Vilas, Asaria, Chen, Babigumira, Dabak and Wee.)

We introduce and illustrate a new framework for distributional economic evaluation of childhood policies that takes a broad and long view of the impacts on health, wellbeing and inequality from a cross-sectoral whole-lifetime perspective. Total lifetime benefits and public cost savings are estimated using lifecourse microsimulation of diverse health, social and economic outcomes for each individual in a general population birth cohort from birth to death. Cost-effectiveness analysis, policy targeting analysis and distributional analysis of inequality impacts are then conducted using an index of lifetime wellbeing that allow comparisons of both value-for-money (efficiency) and distributional impact (equity) from a cross-sectoral lifetime perspective. We illustrate how this framework can be applied in practice by re-evaluating a training programme in England for parents of children at risk of conduct disorder. Our illustration uses a simple index of lifetime wellbeing based on health-related quality of life and consumption, but other indices could be used based on other kinds of outcomes data such as life satisfaction or multidimensional quality of life. We create the detailed underpinning data needed to apply the framework by using a previously published meta-analysis of randomised controlled trials to estimate the short-term effects and a previously published lifecourse microsimulation model to extrapolate the long-term effects., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Recently, two Phase 2B tuberculosis vaccine trials reported positive efficacy results in adolescents and adults. However, experience in vaccinating these age groups is limited. We identified potential implementation strategies for the M72/AS01E vaccination and BCG-revaccination-like candidates and explored their acceptability and feasibility. We conducted in-depth semi-structured interviews among key decision makers to identify implementation strategies and target groups in South Africa, India, and China. Thematic and deductive analysis using a coding framework were used to identify themes across and within settings. In all three countries there was interest in novel TB vaccines, with school-attending adolescents named as a likely target group. In China and India, older people were also identified as a target group. Routine vaccination was preferred in all countries due to stigma and logistical issues with targeted mass campaigns. Perceived benefits for implementation of M72/AS01E were the likely efficacy in individuals with Mycobacterium tuberculosis (Mtb) infection and efficacy for people living with HIV. Perceived challenges for M72/AS01E included the infrastructure and the two-dose regimen required. Stakeholders valued the familiarity of BCG but were concerned about the adverse effects in people living with HIV, a particular concern in South Africa. Implementation challenges and opportunities were identified in all three countries. Our study provides crucial information for implementing novel TB vaccines in specific target groups and on country specific acceptability and feasibility. Key groups for vaccine implementation in these settings were identified, and should be included in clinical trials and implementation planning., Competing Interests: I have read the journal’s policy, and the authors of this manuscript have the following competing interests: Rebecca Harris reports current employment by Sanofi Pasteur; her Sanofi employment includes work on COVID-19, but is unrelated to TB., (Copyright: © 2022 Pelzer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background and Objective: The supply-side threshold for the UK National Health Service has been empirically estimated as the marginal returns to healthcare spending on health outcomes. These estimates implicitly exclude future healthcare costs, which is inconsistent with the objective of making the most efficient use of healthcare resources. This paper illustrates how empirical estimates of the threshold within healthcare can be adjusted to account for future healthcare costs., Methods: Using cause-deleted life tables and previous work on future costs in England and Wales, we illustrate how such estimates can be adjusted., Results: While the effect of including future healthcare costs can have substantial effects on incremental cost-effectiveness ratios of specific life-extending interventions, we find that including future costs has relatively little impact (an increase of £743 per quality-adjusted life-year) on the threshold estimate., Conclusions: For some life-extending interventions the impact of including future costs on whether an intervention is deemed cost effective may be considerable., (© 2021. The Author(s).)

Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest.

Approximately 13% of the total UK workforce is employed in the health and care sector. Despite substantial workforce planning efforts, the effectiveness of this planning has been criticised. Education, training, and workforce plans have typically considered each health-care profession in isolation and have not adequately responded to changing health and care needs. The results are persistent vacancies, poor morale, and low retention. Areas of particular concern highlighted in this Health Policy paper include primary care, mental health, nursing, clinical and non-clinical support, and social care. Responses to workforce shortfalls have included a high reliance on foreign and temporary staff, small-scale changes in skill mix, and enhanced recruitment drives. Impending challenges for the UK health and care workforce include growing multimorbidity, an increasing shortfall in the supply of unpaid carers, and the relative decline of the attractiveness of the National Health Service (NHS) as an employer internationally. We argue that to secure a sustainable and fit-for-purpose health and care workforce, integrated workforce approaches need to be developed alongside reforms to education and training that reflect changes in roles and skill mix, as well as the trend towards multidisciplinary working. Enhancing career development opportunities, promoting staff wellbeing, and tackling discrimination in the NHS are all needed to improve recruitment, retention, and morale of staff. An urgent priority is to offer sufficient aftercare and support to staff who have been exposed to high-risk situations and traumatic experiences during the COVID-19 pandemic. In response to growing calls to recognise and reward health and care staff, growth in pay must at least keep pace with projected rises in average earnings, which in turn will require linking future NHS funding allocations to rises in pay. Through illustrative projections, we show that, to sustain annual growth in the workforce at approximately 2·4%, increases in NHS expenditure of 4% annually in real terms will be required. Above all, a radical long-term strategic vision is needed to ensure that the future NHS workforce is fit for purpose., Competing Interests: Declaration of interests MF is Chair of NHS Wales Shared Services Partnership Committee. MW was a non-executive director of NHS Lothian between February, 2015, to February, 2021. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of interests AzS reports grants from Health Data Research UK BREATHE Hub, outside the submitted work. BC reports in-kind contributions to research projects from Roche Diagnostics and iRhythm, outside the submitted work. BDF reports grants from Cerner and personal fees from Pfizer, outside the submitted work. JNN is employed by Public Health England. MF is the chair of NHS Wales Shared Services Partnership Committee. ML is the chair of the Cwm Taf Morgannwg University Health Board. MoW was a non-executive director of NHS Lothian between February, 2015, and February, 2021. RH is a member of the Health Inequality Advisory Board of Public Health England, governor of the Health Foundation, interim chair at the Food Standards Agency, and Advisory Board member of National Institute for Health Research School of Public Health Research. RR is supported by National Institute for Health Research Applied Research Collaboration North Thames. The views expressed in this publication are those of the author and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. All other authors declare no competing interests.

Objective: To estimate the proportion of ethnic inequalities explained by living in a multi-generational household., Design: Causal mediation analysis., Setting: Retrospective data from the 2011 Census linked to Hospital Episode Statistics (2017-2019) and death registration data (up to 30 November 2020)., Participants: Adults aged 65 years or over living in private households in England from 2 March 2020 until 30 November 2020 (n=10,078,568)., Main Outcome Measures: Hazard ratios were estimated for COVID-19 death for people living in a multi-generational household compared with people living with another older adult, adjusting for geographic factors, socioeconomic characteristics and pre-pandemic health., Results: Living in a multi-generational household was associated with an increased risk of COVID-19 death. After adjusting for confounding factors, the hazard ratios for living in a multi-generational household with dependent children were 1.17 (95% confidence interval [CI] 1.06-1.30) and 1.21 (95% CI 1.06-1.38) for elderly men and women. The hazard ratios for living in a multi-generational household without dependent children were 1.07 (95% CI 1.01-1.13) for elderly men and 1.17 (95% CI 1.07-1.25) for elderly women. Living in a multi-generational household explained about 11% of the elevated risk of COVID-19 death among elderly women from South Asian background, but very little for South Asian men or people in other ethnic minority groups., Conclusion: Elderly adults living with younger people are at increased risk of COVID-19 mortality, and this is a contributing factor to the excess risk experienced by older South Asian women compared to White women. Relevant public health interventions should be directed at communities where such multi-generational households are highly prevalent.

Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest.

Background: Deaths during the COVID-19 pandemic result directly from infection and exacerbation of other diseases and indirectly from deferment of care for other conditions, and are socially and geographically patterned. We quantified excess mortality in regions of England and Wales during the pandemic, for all causes and for non-COVID-19-associated deaths., Methods: Weekly mortality data for 1 January 2010 to 1 May 2020 for England and Wales were obtained from the Office of National Statistics. Mean-dispersion negative binomial regressions were used to model death counts based on pre-pandemic trends and exponentiated linear predictions were subtracted from: (i) all-cause deaths and (ii) all-cause deaths minus COVID-19 related deaths for the pandemic period (week starting 7 March, to week ending 8 May)., Findings: Between 7 March and 8 May 2020, there were 47 243 (95% CI: 46 671 to 47 815) excess deaths in England and Wales, of which 9948 (95% CI: 9376 to 10 520) were not associated with COVID-19. Overall excess mortality rates varied from 49 per 100 000 (95% CI: 49 to 50) in the South West to 102 per 100 000 (95% CI: 102 to 103) in London. Non-COVID-19 associated excess mortality rates ranged from -1 per 100 000 (95% CI: -1 to 0) in Wales (ie, mortality rates were no higher than expected) to 26 per 100 000 (95% CI: 25 to 26) in the West Midlands., Interpretation: The COVID-19 pandemic has had markedly different impacts on the regions of England and Wales, both for deaths directly attributable to COVID-19 infection and for deaths resulting from the national public health response., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

An inverse care law persists in almost all low-income and middle-income countries, whereby socially disadvantaged people receive less, and lower-quality, health care despite having greater need. By contrast, a disproportionate care law persists in high-income countries, whereby socially disadvantaged people receive more health care, but of worse quality and insufficient quantity to meet their additional needs. Both laws are caused not only by financial barriers and fragmented health insurance systems but also by social inequalities in care seeking and co-investment as well as the costs and benefits of health care. Investing in more integrated universal health coverage and stronger primary care, delivered in proportion to need, can improve population health and reduce health inequality. However, trade-offs sometimes exist between health policy objectives. Health-care technologies, policies, and resourcing should be subjected to distributional analysis of their equity impacts, to ensure the objective of reducing health inequalities is kept in sight., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

We introduce a summary wellbeing measure for economic evaluation of cross-sectoral public policies with impacts on health and living standards. We show how to calculate period-specific and lifetime wellbeing using quality-adjusted life years based on widely available data on health-related quality of life and consumption and normative assumptions about three parameters-minimal consumption, standard consumption, and the elasticity of the marginal value of consumption. We also illustrate how these three parameters can be tailored to the decision-making context and varied in sensitivity analysis to provide information about the implications of alternative value judgments. As well as providing a general measure for cost-effectiveness analysis and cost-benefit analysis in terms of wellbeing, this approach also facilitates distributional analysis in terms of how many good years different population subgroups can expect to live under different policy scenarios., (© 2020 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Objective: To address the issue of limited national data on the prevalence and distribution of underlying conditions among COVID-19 deaths between sexes and across age groups., Patients and Methods: All adult (≥18 years) deaths recorded in England and Wales (March 1, 2020, to May 12, 2020) were analyzed retrospectively. We compared the prevalence of underlying health conditions between COVID and non-COVID-related deaths during the COVID-19 pandemic and the age-standardized mortality rate (ASMR) of COVID-19 compared with other primary causes of death, stratified by sex and age group., Results: Of 144,279 adult deaths recorded during the study period, 36,438 (25.3%) were confirmed COVID deaths. Women represented 43.2% (n=15,731) of COVID deaths compared with 51.9% (n=55,980) in non-COVID deaths. Overall, COVID deaths were younger than non-COVID deaths (82 vs 83 years). ASMR of COVID-19 was higher than all other common primary causes of death, across age groups and sexes, except for cancers in women between the ages of 30 and 79 years. A linear relationship was observed between ASMR and age among COVID-19 deaths, with persistently higher rates in men than women across all age groups. The most prevalent reported conditions were hypertension, dementia, chronic lung disease, and diabetes, and these were higher among COVID deaths. Pre-existing ischemic heart disease was similar in COVID (11.4%) and non-COVID (12%) deaths., Conclusion: In a nationwide analysis, COVID-19 infection was associated with higher age-standardized mortality than other primary causes of death, except cancer in women of select age groups. COVID-19 mortality was persistently higher in men and increased with advanced age., (Copyright © 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objectives: In many countries, future unrelated medical costs occurring during life-years gained are excluded from economic evaluation, and benefits of unrelated medical care are implicitly included, leading to life-extending interventions being disproportionately favored over quality of life-improving interventions. This article provides a standardized framework for the inclusion of future unrelated medical costs and demonstrates how this framework can be applied in England and Wales., Methods: Data sources are combined to construct estimates of per-capita National Health Service spending by age, sex, and time to death, and a framework is developed for adjusting these estimates for costs of related diseases. Using survival curves from 3 empirical examples illustrates how our estimates for unrelated National Health Service spending can be used to include unrelated medical costs in cost-effectiveness analysis and the impact depending on age, life-years gained, and baseline costs of the target group., Results: Our results show that including future unrelated medical costs is feasible and standardizable. Empirical examples show that this inclusion leads to an increase in the ICER of between 7% and 13%., Conclusions: This article contributes to the methodology debate over unrelated costs and how to systematically include them in economic evaluation. Results show that it is both important and possible to include future unrelated medical costs., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the determinants of out-of-pocket (OOP) expenses on diabetes-related treatment incurred in patients attending outpatient clinics in a tertiary care hospital in Delhi, India., Study Design: A cross-sectional analysis of baseline data from a quasi-experimental study was conducted over 8 months in 2016 in a major tertiary care hospital in Delhi., Methods: The study included 375 diabetes patients up to 65 years of age on treatment for at least a year without significant complications. Data were collected through a patient interview schedule., Results: Of the previous six scheduled appointments, at least two missed appointments were seen in 267 (71.2%) patients. The average patient's OOP expenditure on diabetes-related medicines was ₹63.5 a month, a similar amount was spent on traveling to and from health facilities. Sixty-four (17.1%) patients took antidiabetic medication for <85% of the days in the previous 3 months., Conclusion: There exists a high burden of missed clinic appointments among diabetes patients in tertiary care government health settings in India. This appears to be related to the high cost in terms of both time and money involved in attending appointments for the modest benefit of a dispensation of a 15-day drug refill. Health policy measures focused on strengthening medication coverage need to explore the balance of costs and benefits when determining the frequency of clinical appointments in these settings., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Perspectives in Clinical Research.)

In most societies, resources are distributed by individuals acting in markets and by governments through some form of collective decision-making process. Economic evaluation offers a set of tools to inform collective decisions by examining the resource requirements and outcomes of alternative policies. The 'societal perspective' has been advocated, but less consideration has been given to what this should include and its practical implementation. This paper presents a framework for economic evaluation of policies with costs and outcomes falling on different sectors (e.g. health, criminal justice, education) and involving different decision makers. It extends the 'impact inventory' developed by the Second Panel on Cost-Effectiveness in Health and Medicine by considering all affected individuals and reflecting how outcomes attributed to an intervention can be compared with outcomes forgone as a result of resources not being available for other purposes. The framework sets out the series of assessments to be made, distinguishing points at which value judgements feed into the evaluation, and the implications of alternative judgements. These assessments reflect the institutional arrangements of public bodies, for example, their funding, the outcomes they consider important and their relative valuations of these outcomes. By avoiding the use of an abstract 'societal perspective', the contribution of the framework is to inform multiple decision makers with different objectives and provide practical guidance on overall societal impact.

The original article can be found online.

Introduction: Concern for health inequalities is an important driver of health policy in India; however, much of the empirical evidence regarding health inequalities in the country is piecemeal focusing only on specific diseases or on access to particular treatments. This study estimates inequalities in health across the whole life course for the entire Indian population. These estimates are used to calculate the socioeconomic disparities in life expectancy at birth in the population., Methods: Population mortality data from the Indian Sample Registration System were combined with data on mortality rates by wealth quintile from the National Family Health Survey to calculate wealth quintile specific mortality rates. Results were calculated separately for males and females as well as for urban and rural populations. Life tables were constructed for each subpopulation and used to calculate distributions of life expectancy at birth by wealth quintile. Absolute gap and relative gap indices of inequality were used to quantify the health disparity in terms of life expectancy at birth between the richest and poorest fifths of households., Results: Life expectancy at birth was 65.1 years for the poorest fifth of households in India as compared with 72.7 years for the richest fifth of households. This constituted an absolute gap of 7.6 years and a relative gap of 11.7 %. Women had both higher life expectancy at birth and narrower wealth-related disparities in life expectancy than men. Life expectancy at birth was higher across the wealth distribution in urban households as compared with rural households with inequalities in life expectancy widest for men living in urban areas and narrowest for women living in urban areas., Conclusion: As India progresses towards Universal Health Coverage, the baseline social distributions of health estimated in this study will allow policy makers to target and monitor the health equity impacts of health policies introduced., Competing Interests: Competing interests: None declared.

The primary focus of this paper is to offer guidance on the analysis of time streams of effects that a project may have so that they can be discounted appropriately. This requires a framework that identifies the common parameters that need to be assessed, whether conducting cost-effectiveness or benefit-cost analysis. The quantification and conversion of the time streams of different effects into their equivalent health, health care cost or consumption effects avoids embedding multiple arguments in discounting policies. This helps to identify where parameters are likely to differ in particular contexts, what type of evidence would be relevant, what is currently known and how this evidence might be strengthened. The current evidence available to support the assessment of the key parameters is discussed and possible estimates and default assumptions are suggested. Reporting the results in an extensive way is recommended. This makes the assessments required explicit so the impact of alternative assumptions can be explored and analysis updated as better estimates evolve. Some projects will have effects across different countries where some or all of these parameters will differ. Therefore, the net present value of a project will be the sum of the country specific net present values rather than the sum of effects across countries discounted at some common rate., (© Society for Benefit-Cost Analysis, 2019.)

Background: Variation exists in the resource categories included in economic evaluations, and National Institute for Health and Care Excellence (NICE) guidance suggests the inclusion only of costs related to the index condition or intervention. However, there is a growing consensus that all healthcare costs should be included in economic evaluations for Health Technology Assessments (HTAs), particularly those related to extended years of life., Objective and Methods: We aimed to quantify the impact of a range of cost categories on the adoption decision about a hypothetical intervention, and uncertainty around that decision, for stable coronary artery disease (SCAD) based on a dataset comprising 94,966 patients. Three costing scenarios were considered: coronary heart disease (CHD) costs only, cardiovascular disease (CVD) costs and all costs. The first two illustrate different interpretations of what might be regarded as related costs., Results: Employing a 20-year time horizon, the highest mean expected incremental cost was when all costs were included (£2468) and the lowest when CVD costs only were included (£2377). The probability of the treatment being cost effective, estimating health opportunity costs using a ratio of £30,000 per quality-adjusted life-year (QALY), was different for each of the CHD (70%) costs, CVD costs (73%) and all costs (56%) scenarios. The results concern a hypothetical intervention and are illustrative only, as such they cannot necessarily be generalised to all interventions and diseases., Conclusions: Cost categories included in an economic evaluation of SCAD impact on estimates of both cost effectiveness and decision uncertainty. With an aging and co-morbid population, the inclusion of all healthcare costs may have important ramifications for the selection of healthcare provision on economic grounds.