Income inequality and its association with COVID-19 cases and deaths: a cross-country analysis in the Eastern Mediterranean region.

INTRODUCTION: There is limited evidence on the associations between economic and social disparities in the Eastern Mediterranean region (EMR) with COVID-19 infections and deaths. This study aims to investigate the relationship between income inequalities using Gini coefficients and COVID-19 cases and deaths per million population in the EMR countries. METHODS: Country-level data on monthly COVID-19 cases and deaths between March 2020 and October 2021, along with data on selected confounders, were collected from publicly available databases. Mixed-effect negative binomial and inverse hyperbolic sine transformation regressions were estimated to examine the association. RESULTS: The study showed that, in the EMR, a unit increase in Gini coefficient is associated with approximately 7.2% and 3.9% increase in COVID-19 cases and deaths per million population, respectively. The magnitude and direction of the association between income inequality and COVID-19 cases and deaths per-million population still remain the same after excluding four warzone countries from the analysis. CONCLUSION: This increase in COVID-19 cases and deaths is underpinned by the fact that a large number of the population in the region is living in conditions of poverty, with inadequate housing, comorbidities and limited or virtually no access to essential healthcare services. Healthcare policy-makers across countries in the region need to implement effective interventions in areas of income inequality, where it may be linked to increasing the risk of COVID-19 cases and deaths.

Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study.

Background: Link worker social prescribing enables health-care professionals to address patients' non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking. Objectives: To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement. Data sources: Quality Outcomes Framework and Secondary Services Use data. Design: Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April-July 2020). Study population and setting: Community-dwelling adults aged 40-74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK. Intervention: Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions. Participants: (1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients. Main outcome measures: The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score. Results: Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (-1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to -£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval -0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems. Limitations: The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise. Conclusions: This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances. Future work: To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts. Trial registration: This trial is registered as ISRCTN13880272. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Social prescribing happens when health-care staff refer patients to a link worker. Link workers support and help patients to access community services to improve their health and well-being. Social prescribing is popular within the NHS, but there is little evidence that it works. We looked at a social prescribing model being delivered in a disadvantaged area in north-east England.

Impact of a link worker social prescribing intervention on non-elective admitted patient care costs: A quasi-experimental study.

Healthcare systems in many countries are enthusiastically adopting link worker social prescribing interventions that aim to tackle the social determinants of health by linking patients to voluntary and community sector activities and sources of support to address their social needs and improve condition management. Social prescribing interventions aim to improve health and reduce healthcare spending. However, despite the diversion of healthcare budgets to fund social prescribing, we still lack robust evidence for its effectiveness. In this study we evaluate whether participation in a social prescribing intervention reduced non-elective admitted patient care use and costs for 8283 patients aged between 40 and 74 years, with a diagnosis of type 2 diabetes and living in an area of high socioeconomic deprivation in north-east England. Patients were followed for a total of 6 years: 2 years pre-intervention and 4 years post intervention. Exploiting a natural experiment, we used a two-part difference-in-differences regression model to estimate costs conditional on healthcare use. We also estimated intervention effects across several intervention and control groups and sample subgroups. Participation in the intervention resulted in reductions of up to -£77.57 [95% CI: -152.30, -2.84] (for high engagement patients) per patient, per year, in non-elective care costs. Reductions were greater for patients with higher levels of engagement with the intervention. Sub-group analyses showed greater cost reductions for non-White patients, older patients, and patients without additional co-morbidities. Our findings suggest that engagement with a link worker social prescribing intervention may reduce non-elective healthcare spending, perhaps through enabling better condition management that results in fewer avoidable health crises.

Intervention components of link worker social prescribing programmes: A scoping review.

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.

Worker adjustment to unexpected occupational risk: Evidence from COVID-19.

We study the link between the revelation of a hitherto non-existent occupational risk - mortality due to the COVID-19 pandemic in 2020 - and subsequent worker behaviour. We link occupation-specific data on COVID-19 mortality to individual level data sets. We find that wages did not adjust, but workers started leaving high-risk occupations during 2020. These effects are stronger for workers not affected by lockdowns or working from home orders and for those considered to be clinically vulnerable to COVID-19 and are not driven by negative health shocks or employer-initiated separations. Occupation-level results suggest that employment began to rebound in 2021.

No new fast-food outlets allowed! Evaluating the effect of planning policy on the local food environment in the North East of England.

The environment in which we live impacts on our health. The food available to us in our environment is likely to influence what we eat and subsequently our weight. The use of planning policy can be one way for both local and national government to help shape a healthy environment. In England there are three main types of planning policy used to promote a healthy food environment: 1) restricting new fast-food outlets near schools; 2) restricting new fast-food outlets if the density of existing outlets has surpassed a certain threshold of all retail outlets, 3) restricting new fast-food outlets if childhood obesity rates are above a certain threshold. In 2015, Gateshead council, a local authority in the North East of England implemented all three types of guidance. We utilise a longitudinal administrative dataset, the Food Standards Agency Food Hygiene Rating Scheme Data, covering the period 2012-2019 on all premises selling or preparing food in Great Britain. To analyse the impact of employing all three types of planning guidance on the density, proportion, and number of fast-food outlets in Gateshead, we employ a propensity score matching difference-in-difference approach. We match small geographical areas in Gateshead (lower super output areas) to other local authorities in the North East with similar demographic characteristics that did not implement planning guidance. Results show a reduction in density of fast-food outlets by 12.45 per 100,000 of the population and a 13.88% decrease in the proportion of fast-food outlets in Gateshead compared to other similar local authorities in the North East. There was a marginally significant reduction in the number of restaurants which became insignificant after controlling for population density. These results suggest that a multi-pronged planning approach significantly changed the proportion and density of fast-food outlets in the food environment in the short term (4 years).

Evaluation of a Community Health Worker Social Prescribing Program Among UK Patients With Type 2 Diabetes.

Importance: Despite lacking robust evidence of effectiveness, health care systems in developed countries are funding holistic community health worker (CHW) social prescribing programs that address social needs and health behaviors as adjuncts to clinical care. Objective: To determine whether a UK National Health Service (NHS) CHW social prescribing program was associated with improved hemoglobin A1c (HbA1c) levels among patients with type 2 diabetes. Design, Setting, and Participants: This cohort study with difference-in-differences analysis was conducted among 8086 patients (4752 in the referral program, 3334 in the control group) in 24 NHS primary care practices in a city in North East England. Patients aged 40 to 74 years with a diagnosis of type 2 diabetes were observed for 8 years, from 2011 through 2019. The statistical analysis was conducted between June 1, 2019, and January 31, 2021. Interventions: A social prescribing program, launched in April 2015, enabling primary care staff to refer patients to CHW support to identify condition management and social needs goals and access voluntary and community sector support to address these goals. Intervention referral was only available in primary care practices in the city's west. The control group included patients in the city's east where referral was unavailable. Main Outcomes and Measures: HbA1c level, a marker of glycemic control. Results: A total of 8086 patients were included in the analysis (mean [SD] age, 57.8 [8.78] years; 3477 women [43%]; 6631 White patients [82%]). Mean (SD) baseline HbA1c levels were 7.56% (1.47%) in the referral program group and 7.44% (1.43%) in the control group. Following introduction of the social prescribing referral program, the referral group experienced an HbA1c reduction of -0.10 percentage points (95% CI, -0.17 to -0.03 percentage points) compared with the control group. The association increased over time: after 3 years the estimated association was -0.14 percentage points (95% CI, -0.24 to -0.03 percentage points). The association was stronger for White patients compared with non-White patients (-0.15 percentage points [95% CI, -0.26 to -0.04 percentage points] after 3 years), those with fewer additional comorbidities (-0.16 percentage points [95% CI, -0.29 to -0.04 percentage points] after 3 years), and those living in the most socioeconomically deprived areas (-0.19 percentage points [95% CI, -0.32 to -0.07 percentage points] after 3 years). Conclusions and Relevance: In this study of UK adults with type 2 diabetes, a social prescribing program with referral to CHWs targeting patients' social needs and health behaviors was associated with improved HbA1c levels, suggesting that holistic CHW interventions may help to reduce the public health burden of type 2 diabetes.

Modelling the size, cost and health impacts of universal basic income: What can be done in advance of a trial?

Opposition to Universal Basic Income (UBI) is encapsulated by Martinelli's claim that 'an affordable basic income would be inadequate, and an adequate basic income would be unaffordable'. In this article, we present a model of health impact that transforms that assumption. We argue that UBI can affect higher level social determinants of health down to individual determinants of health and on to improvements in public health that lead to a number of economic returns on investment. Given that no trial has been designed and deployed with that impact in mind, we present a methodological framework for assessing prospective costs and returns on investment through modelling to make the case for that trial. We begin by outlining the pathways to health in our model of change in order to present criteria for establishing the size of transfer capable of promoting health. We then consider approaches to calculating cost in a UK context to estimate budgetary burdens that need to be met by the state. Next, we suggest means of modelling the prospective impact of UBI on health before asserting means of costing that impact, using a microsimulation approach. We then outline a set of fiscal options for funding any shortfall in returns. Finally, we suggest that fiscal strategy can be designed specifically with health impact in mind by modelling the impact of reform on health and feeding that data cyclically back into tax transfer module of the microsimulation.

Dental attendance and behavioural pathways to adult oral health inequalities.

BACKGROUND: While inequalities in oral health are documented, little is known about the extent to which they are attributable to potentially modifiable factors. We examined the role of behavioural and dental attendance pathways in explaining oral health inequalities among adults in England, Wales and Northern Ireland. METHODS: Using nationally representative data, we analysed inequalities in self-rated oral health and number of natural teeth. Highest educational attainment, equivalised household income and occupational social class were used to derive a latent socioeconomic position (SEP) variable. Pathways were dental attendance and behaviours (smoking and oral hygiene). We used structural equation modelling to test the hypothesis that SEP influences oral health directly and also indirectly via dental attendance and behavioural pathways. RESULTS: Lower SEP was directly associated with fewer natural teeth and worse self-rated oral health (standardised path coefficients, -0.21 (SE=0.01) and -0.10 (SE=0.01), respectively). We also found significant indirect effects via behavioural factors for both outcomes and via dental attendance primarily for self-rated oral health. While the standardised parameters of total effects were similar between the two outcomes, for number of teeth, the estimated effect of SEP was mostly direct while for self-rated oral health, it was almost equally split between direct and indirect effects. CONCLUSION: Reducing inequalities in dental attendance and health behaviours is necessary but not sufficient to tackle socioeconomic inequalities in oral health.

An Examination of Consistency in the Incremental Approach to Willingness to Pay: Evidence Using Societal Values for NHS Dental Services.

INTRODUCTION: Willingness to pay (WTP) is used to generate information about value. However, when comparing 2 or more services using standard WTP techniques, the amounts elicited from participants for the services are often similar, even when individuals state a clear preference for one service over another. An incremental approach has been suggested, in which individuals are asked to first rank interventions and provide a WTP value for their lowest-ranked intervention followed by then asking how much more they are willing to pay for their next preferred choice and so on. To date, evaluation of this approach has disregarded protest responses, which may give information on consistency between stated and implicit rankings. METHODS: A representative sample of the English population (n = 790) were asked to value 5 dental services adopting a societal perspective, using a payment vehicle of additional household taxation per year. The sample was randomized to either the standard or the incremental approach. Performance for both methods is assessed on discrimination between values for interventions and consistency between implicit and stated ranks. The data analysis is the first to retain protest responses when considering consistency between ranks. RESULTS: The results indicate that neither approach provides values that discriminate between interventions. Retaining protest responses reveals inconsistencies between the stated and implicit ranks are present in both approaches but much reduced in the incremental approach. CONCLUSION: The incremental approach does not improve discrimination between values, yet there is less inconsistency between ranks. The protest responses indicate that objections to giving values to the dental interventions are dependent on a multitude of factors beyond the elicitation process.

COVID-19 and income inequality in OECD countries.

OBJECTIVE: To determine the association between income inequality and COVID-19 cases and deaths per million in OECD countries. METHODS: Cross-sectional regression methods are used to model the relationship between income inequality, as measured by the Gini coefficient, and COVID-19 reported cases and deaths per-million. RESULTS: The results demonstrate a significant positive association between income inequality and COVID-19 cases and death per million in all estimated models. A 1% increase in the Gini coefficient is associated with an approximately 4% increase in cases per-million and an approximately 5% increase in deaths per-million. CONCLUSIONS: The results demonstrate that countries with high levels of income inequality have performed significantly worse when dealing with the COVID-19 outbreak in terms cases and deaths. Income inequality is a proxy for many elements of socioeconomic disadvantage that may contribute to the spread of, and deaths from, COVID-19. These include poor housing, smoking, obesity and pollution. POLICY IMPLICATIONS: The findings suggest the importance of closing the gap in income inequality and improving the health and incomes of the poorest and most vulnerable groups.

Combining Health and Outcomes Beyond Health in Complex Evaluations of Complex Interventions: Suggestions for Economic Evaluation.

In this journal there has been considerable discussion regarding the development of tools for valuing the multiple attributes that arise from complex interventions with benefits beyond health. Nevertheless, unlike the rigorous underpinnings of cost-utility analysis, much of this work has been taking place in fragmented research communities and without theoretical underpinnings, leading to a call for better and more comprehensive frameworks. We discuss the challenges faced by economic evaluation using as our example a "social prescribing" intervention, a novel health intervention based on the social model of health. We suggest a mixed-methods approach to uncover important attributes and then combine tools from health economics and economics to provide measures of benefit in a common money numeraire. This approach provides the theoretical underpinnings necessary for deliberate, transparent, and structured decision-making processes. It also enables the correct allocation of costs within complex payment systems. We suggest that, because of the complexities of randomized controlled trials, interventions should be introduced in a way that allows the application of causal analysis for evaluation. In the short term, such evaluations may be challenging and expensive. Nevertheless, as has happened with health economics evaluation and the quality-adjusted life-year, when a common set of attributes is agreed upon, the expense will fall and these methods can become embedded in interventions with diffuse outcomes.

Evaluating the impact of a community-based social prescribing intervention on people with type 2 diabetes in North East England: mixed-methods study protocol.

INTRODUCTION: Social prescribing enables healthcare professionals to use voluntary and community sector resources to improve support for people with long-term conditions. It is widely promoted in the UK as a way to address complex health, psychological and social issues presented in primary care, yet there is insufficient evidence of effectiveness or value for money. This study aims to evaluate the impact and costs of a link-worker social prescribing intervention on the health and healthcare use of adults aged 40-74 with type 2 diabetes, living in a multi-ethnic area of high socioeconomic deprivation. METHODS AND ANALYSIS: Mixed-methods approach combining (1) quantitative quasi-experimental methods to evaluate the effects of social prescribing on health and healthcare use and cost-effectiveness analysis and (2) qualitative ethnographic methods to observe how patients engage with social prescribing. Quantitative data comprise Secondary Uses Service data and Quality Outcomes Framework data. The primary outcome is glycated haemoglobin, and secondary outcomes are secondary care use, systolic blood pressure, weight/body mass index, cholesterol and smoking status; these data will be analysed longitudinally over 3 years using four different control conditions to estimate a range of treatment effects. The ranges where the intervention is cost-effective will be identified from the perspective of the healthcare provider. Qualitative data comprise participant observation and interviews with purposively sampled service users, and focus groups with link-workers (intervention providers). Analysis will involve identification of themes and synthesising and theorising the data. Finally, a coding matrix will identify convergence and divergence among all study components. ETHICS AND DISSEMINATION: UK NHS Integrated Research Approval System Ethics approved the quantitative research (Reference no. 18/LO/0631). Durham University Research Ethics Committee approved the qualitative research. The authors will publish the findings in peer-reviewed journals and disseminate to practitioners, service users and commissioners via a number of channels including professional and patient networks, conferences and social media. Results will be disseminated via peer-reviewed journals.

Resource allocation in NHS dentistry: recognition of societal preferences (RAINDROP): study protocol.

BACKGROUND: Resources in any healthcare systems are scarce relative to need and therefore choices need to be made which often involve difficult decisions about the best allocation of these resources. One pragmatic and robust tool to aid resource allocation is Programme Budgeting and Marginal Analysis (PBMA), but there is mixed evidence on its uptake and effectiveness. Furthermore, there is also no evidence on the incorporation of the preferences of a large and representative sample of the general public into such a process. The study therefore aims to undertake, evaluate and refine a PBMA process within the exemplar of NHS dentistry in England whilst also using an established methodology (Willingness to Pay (WTP)) to systematically gather views from a representative sample of the public. METHODS: Stakeholders including service buyers (commissioners), dentists, dental public health representatives and patient representatives will be recruited to participate in a PBMA process involving defining current spend, agreeing criteria to judge services/interventions, defining areas for investment and disinvestment, rating these areas against the criteria and making final recommendations. The process will be refined based on participatory action research principles and evaluated through semi-structured interviews, focus groups and observation of the process by the research team. In parallel a representative sample of English adults will be recruited to complete a series of four surveys including WTP valuations of programmes being considered by the PBMA panel. In addition a methodological experiment comparing two ways of eliciting WTP will be undertaken. DISCUSSION: The project will allow the PBMA process and particularly the use of WTP within it to be investigated and developed. There will be challenges around engagement with the task by the panel undertaking it and with the outputs by stakeholders but careful relationship building will help to mitigate this. The large volume of data will be managed through careful segmenting of the analysis and the use of the well-established Framework approach to qualitative data analysis. WTP has various potential biases but the elicitation will be carefully designed to minimise these and some methodological investigation will take place.

Childhood socioeconomic conditions and teeth in older adulthood: Evidence from SHARE wave 5.

OBJECTIVES: Dental diseases are the most common chronic diseases worldwide. Healthy teeth are vital for quality of life, particularly diet and nutrition. However, little information exists to inform health policymakers about potentially long-lasting influences of early-life conditions. The purpose of this study was to investigate the relation between early-life socioeconomic conditions and number of natural teeth at age 50 and above. METHODS: Analyses were conducted on cross-sectional data from the Survey of Health, Ageing and Retirement in Europe (SHARE wave 5), which includes information on 41 560 respondents aged 50 years or older from 14 European countries and Israel. Using SHARE life history information, a series of regression models (OLS, Tobit) were estimated to analyse the relationship between socioeconomic conditions in earlier life and the number of teeth at age 50+. RESULTS: Childhood socioeconomic background was associated with the number of natural teeth at age 50 and above, even after controlling for current determinants of oral health. Respondents who had had more than 25 books in their childhood household had a mean 1.4 (95% CI: 1.2-1.5) more teeth than respondents with fewer books. Respondents who reported poor financial conditions during childhood had a mean 0.6 (95% CI: 0.3-0.9) fewer teeth than respondents who reported better financial conditions in childhood. CONCLUSION: These findings substantiate the association between socioeconomic conditions in the early years of life and tooth retention to older adulthood and highlight the long-lasting relation between childhood living conditions and oral health through the lifecourse.

Explaining time changes in oral health-related quality of life in England: a decomposition analysis.

BACKGROUND: Oral diseases are highly prevalent and impact on oral health-related quality of life (OHRQoL). However, time changes in OHRQoL have been scarcely investigated in the current context of general improvement in clinical oral health. This study aims to examine changes in OHRQoL between 1998 and 2009 among adults in England, and to analyse the contribution of demographics, socioeconomic characteristics and clinical oral health measures. METHODS: Using data from two nationally representative surveys in England, we assessed changes in the Oral Health Impact Profile-14 (OHIP-14), in both the sample overall (n=12 027) and by quasi-cohorts. We calculated the prevalence and extent of oral impacts and summary OHIP-14 scores. An Oaxaca-Blinder type decomposition analysis was used to assess the contribution of demographics (age, gender, marital status), socioeconomic position (education, occupation) and clinical measures (presence of decay, number of missing teeth, having advanced periodontitis). RESULTS: There were significant improvements in OHRQoL, predominantly among those that experienced oral impacts occasionally, but no difference in the proportion with frequent oral impacts. The decomposition model showed that 43% (-4.07/-9.47) of the decrease in prevalence of oral impacts reported occasionally or more often was accounted by the model explanatory variables. Improvements in clinical oral health and the effect of ageing itself accounted for most of the explained change in OHRQoL, but the effect of these factors varied substantially across the lifecourse and quasi-cohorts. CONCLUSIONS: These decomposition findings indicate that broader determinants could be primarily targeted to influence OHRQoL in different age groups or across different adult cohorts.