Patient characteristics associated with enrolment under voluntary programs implemented within fee-for-service systems in British Columbia and Quebec: a cross-sectional study.

BACKGROUND: There is a paucity of information on patient characteristics associated with enrolment under voluntary programs (e.g. incentive payments) implemented within fee-for-service systems. We explored patient characteristics associated with enrolment under these programs in British Columbia and Quebec. METHODS: We used linked administrative data and a cross-sectional design to compare people aged 40 years or more enrolled under voluntary programs to those who were eligible but not enrolled. We examined 2 programs in Quebec (enrolment of vulnerable patients with qualifying conditions [implemented in 2003] and enrolment of the general population [2009]) and 3 in BC (Chronic disease incentive [2003], Complex care incentive [2007] and enrolment of the general population [A GP for Me, 2013]). We used logistic regression to estimate the odds of enrolment by neighbourhood income, rural versus urban residence, previous treatment for mental illness, previous treatment for substance use disorder and use of health care services before program implementation, controlling for characteristics linked to program eligibility. RESULTS: In Quebec, we identified 1 569 010 people eligible for the vulnerable enrolment program (of whom 505 869 [32.2%] were enrolled within the first 2 yr of program implementation) and 2 394 923 for the general enrolment program (of whom 352 380 [14.7%] were enrolled within the first 2 yr). In BC, we identified 133 589 people eligible for the Chronic disease incentive, 47 619 for the Complex care incentive and 1 349 428 for A GP for Me; of these, 60 764 (45.5%), 28 273 (59.4%) and 1 066 714 (79.0%), respectively, were enrolled within the first 2 years. The odds of enrolment were higher in higher-income neighbourhoods for programs without enrolment criteria (adjusted odds ratio [OR] comparing highest to lowest quintiles 1.21 [95% confidence interval (CI) 1.20-1.23] in Quebec and 1.67 [95% CI 1.64-1.69] in BC) but were similar across neighbourhood income quintiles for programs with health-related eligibility criteria. The odds of enrolment by urban versus rural location varied by program. People treated for substance use disorders had lower odds of enrolment in all programs (adjusted OR 0.60-0.72). Compared to people eligible but not enrolled, those enrolled had similar or higher numbers of primary care visits and longitudinal continuity of care in the year before enrolment. INTERPRETATION: People living in lower-income neighbourhoods and those treated for substance use disorders were less likely than people in higher-income neighbourhoods and those not treated for such disorders to be enrolled in programs without health-related eligibility criteria. Other strategies are needed to promote equitable access to primary care.

Required and Voluntary Occupational Use of Hazard Controls for COVID-19 Prevention in Non-Health Care Workplaces - United States, June 2020.

Certain hazard controls, including physical barriers, cloth face masks, and other personal protective equipment (PPE), are recommended to reduce coronavirus 2019 (COVID-19) transmission in the workplace (1). Evaluation of occupational hazard control use for COVID-19 prevention can identify inadequately protected workers and opportunities to improve use. CDC's National Institute for Occupational Safety and Health used data from the June 2020 SummerStyles survey to characterize required and voluntary use of COVID-19-related occupational hazard controls among U.S. non-health care workers. A survey-weighted regression model was used to estimate the association between employer provision of hazard controls and voluntary use, and stratum-specific adjusted risk differences (aRDs) among workers reporting household incomes <250% and ≥250% of national poverty thresholds were estimated to assess effect modification by income. Approximately one half (45.6%; 95% confidence interval [CI] = 41.0%-50.3%) of non-health care workers reported use of hazard controls in the workplace, 55.5% (95% CI = 48.8%-62.2%) of whom reported employer requirements to use them. After adjustment for occupational group and proximity to others at work, voluntary use was approximately double, or 22.3 absolute percentage points higher, among workers who were provided hazard controls than among those who were not. This effect was more apparent among lower-income (aRD = 31.0%) than among higher-income workers (aRD = 16.3%). Employers can help protect workers from COVID-19 by requiring and encouraging use of occupational hazard controls and providing hazard controls to employees (1).

Spillover Effects of Medicare's Voluntary Bundled Payments for Joint Replacement Surgery to Patients Insured by Commercial Health Plans.

BACKGROUND: Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries. OBJECTIVE: To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA). DESIGN: Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016. SETTING: LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals. PATIENTS: 184 922 patients with MA or commercial insurance. MEASUREMENTS: Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers. RESULTS: Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; P = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; P = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status. LIMITATION: Nonrandomized studies are subject to residual confounding and selection. CONCLUSION: Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage. PRIMARY FUNDING SOURCE: Leonard Davis Institute of Health Economics at the University of Pennsylvania.

Perceived influence of value systems on the uptake of voluntary medical male circumcision among men in Kweneng East, Botswana.

Botswana is one of the countries in Eastern and Southern Africa significantly impacted by the Human Immunodeficiency Virus (HIV). To control the spread of HIV, the government in 2009 rolled out the voluntary medical male circumcision (VMMC) programme as an additional HIV prevention strategy with the goal of circumcising 80% of HIV negative men by 2016. However, the country failed to achieve this goal as less than 30% of the targeted men were circumcised by 2016. A study was therefore conducted to explore and describe the factors that are perceived by men in Botswana to influence the uptake of VMMC in order to inform future policymaking and programming on VMMC. An exploratory descriptive, qualitative design was utilised to investigate perceived factors influencing the uptake of VMMC among men. Data were collected from 38 men, aged 18-49 years in Kweneng East, Botswana using semi-structured individual interviews and focus group discussions (FGDs). Tesch's method of qualitative data analysis was used to code and categorise transcribed data into meaningful themes. Upon analysis, three themes emerged as influencing the uptake of VMMC: (a) the influence of value systems associated with stakeholder consultation in the community; (b) the influence of value systems associated with cultural beliefs and (c) the influence of value systems associated with religious beliefs. The influence of value systems associated with stakeholder consultation in the community was found to manifest in the form of the lack of consultation with men at the inception of the VMMC; the lack of involvement of village elders during the service delivery process and the lack of involvement of women in VMMC. In addition, the influence of value systems associated with cultural beliefs was found to manifest in the form of the lack of openness between parents and children on sexual matters and the lack of traditional leadership support in VMMC. Lastly, the influence of value systems associated with religious beliefs was found to manifest in the form of religious views not in support of the VMMC and religious views in support of the VMMC. It is concluded that value systems associated with stakeholder consultation, cultural beliefs and religious beliefs were the factors influencing the uptake of VMMC among men in Kweneng East, Botswana, and these factors to a larger extent deterred men from using VMMC services. Based on these findings, it is therefore concluded that government and other providers of VMMC should consider the influence of value systems on the uptake of VMMC in order to provide culturally congruent VMMC services and boost of the uptake of VMMC among men in Kweneng East, Botswana.

Social and behavioral consequences of mask policies during the COVID-19 pandemic.

Mandatory and voluntary mask policies may have yet unknown social and behavioral consequences related to the effectiveness of the measure, stigmatization, and perceived fairness. Serial cross-sectional data (April 14 to May 26, 2020) from nearly 7,000 German participants demonstrate that implementing a mandatory policy increased actual compliance despite moderate acceptance; mask wearing correlated positively with other protective behaviors. A preregistered experiment (n = 925) further indicates that a voluntary policy would likely lead to insufficient compliance, would be perceived as less fair, and could intensify stigmatization. A mandatory policy appears to be an effective, fair, and socially responsible solution to curb transmissions of airborne viruses.

HIV Prevalence and Factors Influencing the Uptake of Voluntary HIV Counseling and Testing among Older Clients of Female Sex Workers in Liuzhou and Fuyang Cities, China, 2016-2017: A Cross-Sectional Study.

OBJECTIVE: To compare the prevalence of HIV and associated factors for participating HIV voluntary counseling and testing (VCT) among older clients of female sex workers (CFSWs) in Liuzhou City and Fuyang City in China. METHODS: A cross-sectional study was conducted and the study employed 978 male CFSWs, aged 50 years and above from October 2016 to December 2017. All participants were required to complete a questionnaire and provide blood samples for HIV testing. Multivariate logistic regression analysis was used to analyze the influential factors of using VCT program and tested for HIV. RESULTS: The HIV infection prevalence rate was 1.2% and 0.5%, while 52.3% and 54.6% participants had ever utilized VCT service and tested for HIV in Liuzhou City and Fuyang City, respectively. The older CFSWs who ever heard of VCT program were more likely to uptake VCT program in both cities (ORLiuzhou = 2.224, ORFuyang = 2.421). Participants, whose marital status was married or cohabiting (ORLiuzhou = 0.548, ORFuyang = 0.495), who have stigma against individuals who are living with HIV/AIDS (ORLiuzhou = 0.273, ORFuyang = 0.371), whose monthly income is more than 500 yuan (ORLiuzhou = 0.622, ORFuyang = 0.600), and whose age is more than 60 years old (ORLiuzhou = 0.639, ORFuyang = 0.554), were less likely to visit VCT clinics. Those who are worried about HIV-infected participants were more likely to utilize VCT services in Fuyang City (AOR = 1.838, 95%CI : 1.146-2.948). CONCLUSION: Combine strategy will be needed to promote the utilization of VCT service, based on the socioeconomic characteristics of older male CFSWs in different cities of China.

Voluntary private health insurance demand determinants and risk preferences: Evidence from SHARE.

The demand for voluntary private health insurance (VPHI) in universal coverage health systems in Europe raises some questions. The aim of this paper is to determine the factors that explain the decision to purchase VPHI, to analyse the role of individual risk attitudes and self-assessed health (SAH) in purchasing VPHI, to explore the factors that explain individual risk preferences, and to test how SAH relates to those preferences. To achieve this aim, two recursive simultaneous probits are estimated using data collected by SHARE, wave 6. The main results indicate that people who are more satisfied with the health system coverage are more likely to buy VPHI; SAH is negative correlated with VPHI, but being a risk taker contributes to that decision; however, being a risk taker is positively influenced by good health status. This paper contributes to the discussion on the role of SAH and risk preferences in the decision to buy VPHI. It brings new insights for the health insurance companies and for health policy makers. HIGHLIGHTS: People who are more satisfied with the health system coverage are more likely to buy voluntary private health insurance. The longer the planning horizon assumed by individuals, the greater the likelihood they are risk takers. People reporting being risk takers are more likely to have taken out voluntary private health insurance. Self-assessed health influences the decision to buy voluntary private health insurance in two ways: a direct one, where better health lowers the odds of having insurance, and an indirect one through risk taking, which increases the odds of having insurance. Contributions of this work are mainly for health policy makers and insurance companies.

Estudio de la percepción de los profesionales implicados en el proceso de suministro de medicación a ancianos que viven en residencias desde una farmacia comunitaria / Study of the perception of the professionals involved in the process of administering medications to the elderly who live in residences from a community pharmacy

Introducción: la consulta a los profesionales implicados en el proceso de suministro de medicación a los centros sociosanitarios permite conocer su percepción sobre dicho proceso y las posibles mejoras que se puedan introducir en él, como la implantación de un protocolo que estandarice toda la cadena de suministro. Material y métodos: estudio observacional descriptivo realizado en dos residencias de ancianos con una muestra de 50 profesionales voluntarios, que respondieron de forma anónima a un cuestionario elaborado ad hoc para la investigación. Resultados: un 76 % da mucha importancia a la cadena de suministro de medicación al anciano. El 78 % vio relevante la implantación de un protocolo que regule el proceso. El 72 % destacó como muy importante la relación entre farmacia comunitaria y residencia. El 54 % opinó que la limitada legibilidad de lo escrito en la orden de prescripción produce errores. El 34 % señaló que nunca hay errores por confusión de horarios de administración, dosis o duración de tratamientos. El 58 % indicó que pocas veces hay errores relacionados con la transmisión de información. El 86 % opinó que nunca se producen errores por el envío de la orden de prescripción a la farmacia comunitaria. Conclusiones: la atención farmacéutica al anciano en centros sociosanitarios y la implantación de un protocolo que regule todo el proceso de suministro de medicación fueron consideradas muy importantes por la mayoría de los profesionales implicados en el proceso. El ambiente positivo de colaboración generado por la consulta ha llevado a plantear a los participantes el diseño de un protocolo

Background and aim: The query to the professionals involved in the process of supplying medication to the socio-health centers allows us to understand their perception of the process and the possible improvements that could be made to the supply chain, such as the implemen-tation of a protocol that standardizes the entire supply chain.Methods and results: A descriptive observational study conducted in two nursing homes with a sample of 50 volunteer professionals, who responded anonymously to a questionnaire prepared ad hoc for researchOutcomes: 76 % of respondants saw the importance in the medication supply chain to the elderly. 78 % saw the implementation of a protocol that regulates the process as relevant. 72 % highlighted the relationship between the Cummunity Pharmacy and residence as very important. 54 % thought that the limited readability of what was written in the prescription order produces errors. 34 % indicated there are never errors due to confusion of administration schedules, doses or duration of treatments. 58 % indicated there are rarely errors related to the transmission of information. 86 % thought errors do not occur in the proccess of sending the prescription order to the Community Pharmacy.Conclusions: Pharmaceutical care for the elderly in socio-health centers and the implementation of a protocol which regulates the entire medication supply process were considered very important by the majority of professionals involved in the process. The positive collaboration environment generated by the consultation has made think to the participants about the design of a protocol

Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets.

INTRODUCTION: Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President's Emergency Plan for AIDS Relief's (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. METHODS AND RESULTS: The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including "mobilizers", HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. CONCLUSION: Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.

Rollout of ShangRing circumcision with active surveillance for adverse events and monitoring for uptake in Kenya.

INTRODUCTION: Since 2011, Kenya has been evaluating ShangRing device for use in its voluntary medical male circumcision (VMMC) program according to World Health Organization (WHO) guidelines. Compared to conventional surgical circumcision, the ShangRing procedure is shorter, does not require suturing and gives better cosmetic outcomes. After a pilot evaluation of ShangRing in 2011, Kenya conducted an active surveillance for adverse events associated with its use from 2016-2018 to further assess its safety, uptake and to identify any operational bottlenecks to its widespread use based on data from a larger pool of procedures in routine health care settings. METHODS: From December 2017 to August 2018, HIV-negative VMMC clients aged 13 years or older seeking VMMC at six sites across five counties in Kenya were offered ShangRing under injectable local anesthetic as an alternative to conventional surgical circumcision. Providers described both procedures to clients before letting them make a choice. Outcome measures recorded for clients who chose ShangRing included the proportions who were clinically eligible, had successful device placement, experienced adverse events (AEs), or failed to return for device removal. Clients failing to return for follow up were sought through phone calls, text messages or home visits to ensure removal and complete information on adverse events. RESULTS: Out of 3,692 eligible clients 1,079 (29.2%) chose ShangRing; of these, 11 (1.0%) were excluded due to ongoing clinical conditions, 17 (1.6%) underwent conventional surgery due to lack of appropriate device size at the time of the procedure, 97.3% (1051/1079) had ShangRing placement. Uptake of ShangRing varied from 11% to 97% across different sites. There was one severe AE, a failed ShangRing placement (0.1%) managed by conventional wound suturing, plus two moderate AEs (0.2%), post removal wound dehiscence and bleeding, that resolved without sequelae. The overall AE rate was 0.3%. All clients returned for device removal from fifth to eleventh day after placement. CONCLUSION: ShangRing circumcision is effective and safe in the Kenyan context but its uptake varies widely in different settings. It should be rolled out under programmatic implementation for eligible males to take advantage of its unique benefits and the freedom of choice beyond conventional surgical MMC. Public education on its availability and unique advantages is necessary to optimize its uptake and to actualize the benefit of its inclusion in VMMC programs.

Curriculum requirements and subsequent civic engagement: is there a difference between 'forced' and 'free' community service?

Despite figures showing the growth of mandatory community service programmes, there is mixed empirical evidence of their effectiveness. This paper addresses the relationship of mandated community service to one of its purported aims: subsequent volunteerism. It compares current volunteerism among four university student cohorts: those doing no service in secondary school, those volunteering with no requirement, those volunteering both before and after the introduction of a requirement, and those introduced to service through a requirement. The analysis indicates that (1) students who were introduced to service through a mandated programme exhibit current levels of engagement no greater than non-volunteers; (2) this relationship stems largely from the different service experiences of our four cohorts and relates to the fact that service satisfaction and duration, as well as background variables account for current levels of civic engagement. The findings suggest that mandatory service programmes might well be failing the very population they seek to target, particularly in weaker, less structured programmes.

Patient Characteristics Associated With Voluntary Safety Event Reporting in the Acute Care Setting.

OBJECTIVES: Adverse events are increasingly important to health care delivery and financial reimbursement. Most hospitals use voluntary event reporting (VER) systems to detect safety events, which may be vulnerable to individual and systemic biases. We tested the hypothesis that patient demographic factors such as weight status and race would be associated with safety event reporting in the acute care setting. METHODS: We reviewed all acute care encounters for patients 2 to 17 years of age and corresponding safety events entered in the VER system of a tertiary-care children's hospital from February 2015 to February 2016. Data collected included patient demographics, clinical characteristics, incident description, and reported harm score. Our primary outcome was any report of a safety event. Using χ2 and multivariable logistical regression methods, we determined patient characteristics associated with safety event reporting. RESULTS: A total of 22 056 patient encounters were identified, and 341 (1.5%) of those had a reported safety event. In univariate analysis, age, weight category, and race were found to be significantly associated with event reporting, whereas sex and insurance provider were not. In the multivariable logistic regression model, obesity (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.49-0.97) and African American race (OR 0.65; 95% CI 0.46-0.93) were negatively associated with event reporting, whereas length of stay was positively associated (OR 1.51; 95% CI 1.46-1.55). CONCLUSIONS: We identified associations between patient demographic factors and voluntary safety event reporting in the acute care setting. In future studies, we will compare VER to event identification by more objective measures, such as a trigger tool.

Data triangulation to estimate age-specific coverage of voluntary medical male circumcision for HIV prevention in four Kenyan counties.

BACKGROUND: Kenya is 1 of 14 priority countries in Africa scaling up voluntary medical male circumcision (VMMC) for HIV prevention following the recommendations of the World Health Organization and the Joint United Nations Programme on HIV/AIDS. To inform VMMC target setting, we modeled the impact of circumcising specific client age groups across several Kenyan geographic areas. METHODS: The Decision Makers' Program Planning Tool, Version 2 (DMPPT 2) was applied in Kisumu, Siaya, Homa Bay, and Migori counties. Initial modeling done in mid-2016 showed coverage estimates above 100% in age groups and geographic areas where demand for VMMC continued to be high. On the basis of information obtained from country policy makers and VMMC program implementers, we adjusted circumcision coverage for duplicate reporting, county-level population estimates, migration across county boundaries for VMMC services, and replacement of traditional circumcision with circumcisions in the VMMC program. To address residual inflated coverage following these adjustments we applied county-specific correction factors computed by triangulating model results with coverage estimates from population surveys. RESULTS: A program record review identified duplicate reporting in Homa Bay, Kisumu, and Siaya. Using county population estimates from the Kenya National Bureau of Statistics, we found that adjusting for migration and correcting for replacement of traditional circumcision with VMMC led to lower estimates of 2016 male circumcision coverage especially for Kisumu, Migori, and Siaya. Even after addressing these issues, overestimation of 2016 male circumcision coverage persisted, especially in Homa Bay. We estimated male circumcision coverage in 2016 by applying correction factors. Modeled estimates for 2016 circumcision coverage for the 10- to 14-year age group ranged from 50% in Homa Bay to approximately 90% in Kisumu. Results for the 15- to 19-year age group suggest almost complete coverage in Kisumu, Migori, and Siaya. Coverage for the 20- to 24-year age group ranged from about 80% in Siaya to about 90% in Homa Bay, coverage for those aged 25-29 years ranged from about 60% in Siaya to 80% in Migori, and coverage in those aged 30-34 years ranged from about 50% in Siaya to about 70% in Migori. CONCLUSIONS: Our analysis points to solutions for some of the data issues encountered in Kenya. Kenya is the first country in which these data issues have been encountered because baseline circumcision rates were high. We anticipate that some of the modeling methods we developed for Kenya will be applicable in other countries.

A Quarter Century of Participation in School-Based Extracurricular Activities: Inequalities by Race, Class, Gender and Age?

Extracurricular activity participation is linked to positive development, but it is also a setting for inequality. Using a quarter century of data from Monitoring the Future (N = 593,979; 51% female; 65% non-Hispanic white; 13% non-Hispanic black; 12% Hispanic; 4% non-Hispanic Asian/Pacific Islander; 7% other race), this article documents patterns and trends in school-based extracurricular participation by race, social class, gender, and age, and their links to academic and substance use outcomes. Findings reveal differences by race and confirm a division by social class that has worsened over time. Further, girls are gaining on boys and surpass them in some types of school-based activities. Participation is linked to better academic outcomes and less substance use, affirming the importance of redressing the inequalities revealed.

Income inequality in uptake of voluntary versus organised breast cancer screening: evidence from the British Household Panel Survey.

BACKGROUND: This paper measures income-related inequality in uptake of breast cancer screening among women before and after a policy change to extend the screening programme to women aged 65 to 70. Prior to programme expansion women aged 50 to 64 were invited for screening under the national cancer screening programme in England and Wales whereas women in the 65 to 70 age cohort could elect to be screened by personally organising a screen. This will give a deeper insight into the nature of inequality in screening and the impact of policies aimed at widening the access related to age on inequality of uptake. METHODS: Taking advantage of this natural experiment, inequality is quantified across the different age cohorts and time periods with the use of concentration indices (CI). Using data from the British Household Panel Survey, information on screening attendance, equivalised household income and age was taken for the three years prior to the programme expansion and the three years immediately following the policy change. RESULTS: Results show that following the expansion, inequality significantly reduced for the 50-64 age group, prior to the expansion there was a pro-rich inequality in screening uptake. There is also evidence of a reduction in income inequality in screening uptake among those aged 65 to 70 and an increase in the number of women attending screening from this older age cohort. CONCLUSIONS: This indicates that an organised breast screening programme is likely to reduce income related inequality over a screening programme where women must organise their own screen. This is important when breast screening is one of the main methods used to detect breast cancer at an earlier stage which improves outcomes for women and reduces treatment costs.

Examining Relationships among Choice, Affect, and Engagement in Summer STEM Programs.

Out-of-school time programs focused on science, technology, engineering and mathematics (STEM) have proliferated recently because they are seen as having potential to appeal to youth and enhance STEM interest. Although such programs are not mandatory, youth are not always involved in making the choice about their participation and it is unclear whether youth's involvement in the choice to attend impacts their program experiences. Using data collected from experience sampling, traditional surveys, and video recordings, we explore relationships among youth's choice to attend out-of-school time programs (measured through a pre-survey) and their experience of affect (i.e., youth experience sampling ratings of happiness and excitement) and engagement (i.e., youth experience sampling ratings of concentration and effort) during program activities. Data were collected from a racially and ethnically diverse sample of 10-16 year old youth (n = 203; 50% female) enrolled in nine different summer STEM programs targeting underserved youth. Multilevel analysis indicated that choice and affect are independently and positively associated with momentary engagement. Though choice to enroll was a significant predictor of momentary engagement, positive affective experiences during the program may compensate for any decrements to engagement associated with lack of choice. Together, these findings have implications for researchers, parents, and educators and administrators of out-of-school time programming.

Analysis of a voluntary initiative to reduce sodium in processed and ultra-processed food products in Argentina: the views of public and private sector representatives.

The Less Salt, More Life program was the first voluntary salt reduction initiative in Argentina. This article analyzes the perspectives of the stakeholders involved in this voluntary agreement between the Ministry of Health and the food industry to gradually reduce sodium content in processed foods. This exploratory case study used a qualitative approach including 29 in-depth interviews with stakeholders from the public and private sectors and identified the role of the different stakeholders and their perceptions regarding the challenges encountered in the policy process that contribute to the debate on public-private partnerships in health policies. The article also discusses the initiative's main challenges and controversies.

Prevalence of preoperative penile abnormalities among voluntary male medical circumcision patients in Swaziland.

BACKGROUND: Circumcision has been found to be an effective strategy for lowering the transmission of HIV in Africa. The Luke Commission, a mobile hospital outreach program, has used this information to decrease the rate of HIV in Swaziland by performing voluntary male medical circumcisions throughout the country. During many of these circumcisions, genital medical conditions and penile abnormalities are simultaneously discovered and corrected. PURPOSE: The goal of our study was to evaluate the prevalence of penile abnormalities discovered and treated during voluntary male medical circumcisions performed by The Luke Commission (TLC) throughout rural Swaziland. BASIC PROCEDURES: We completed a retrospective analysis of all male patients who underwent voluntary male medical circumcision performed by TLC during a period from June-August, 2014. The penile abnormalities included: phimosis, paraphimosis, epispadias, hypospadias, ulcers, balanitis, torsion, and foreskin adherent to the glans. MAIN FINDINGS: Of 929 total circumcisions, 771 (83%) patients had at least one pre-existing penile abnormality identified during their examinations and procedures, totaling 1110 abnormalities. Three specific abnormalities were detected - phimosis, adherent foreskin, and hypospadias. The 6-12 and 13-19 age groups had adequate sample sizes to yield precise estimates of prevalence (age group 6-12: 87% (95% confidence interval [CI]=84-90%; age group 13-19: 79% (95% CI=74-84%). PRINCIPLE CONCLUSIONS: The Luke Commission is improving the lives of children and adults with limited access to healthcare through regular preoperative evaluations during male circumcision, and the organization is setting an example for other international healthcare groups. LEVEL OF EVIDENCE: Type of Study: Prognostic Study, Level II.