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  • Journal article
    Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, El Arnaout N, Karroum LB, Jawad M, Roborgh S, Abbara A, Alhalabi F, AlMasri I, Jabbour Set al., 2017,

    Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria

    , LANCET, Vol: 390, Pages: 2516-2526, ISSN: 0140-6736
  • Journal article
    Filippidis FT, Gerovasili V, Millett C, Tountas Yet al., 2017,

    Medium-term impact of the economic crisis on mortality, health-related behaviours and access to healthcare in Greece

    , Scientific Reports, Vol: 7, ISSN: 2045-2322

    Previous studies on the health consequences of the crisis in Greece investigated short-term impacts on selected outcomes. This study examined the impact of the crisis on a key set of health indicators with longer follow up than previous studies. We conducted interrupted time series (ITS) analysis to compare trends in standardised mortality by cause before and during the crisis. We examined changes in fruit and vegetable consumption, smoking, physical activity, obesity, out-of-pocket payments and unmet needs for healthcare using national household data from the “Hellas Health” surveys. Standardised mortality rates for suicides (p < 0.001) and infant mortality (p = 0.003) increased during the crisis compared to pre-existing trends, while mortality from respiratory diseases (p = 0.053) and transport accidents (p = 0.067) decreased. The prevalence of smoking (42.6% to 36.5%; RR = 0.86) and sedentary lifestyle (43.4% to 29.0%; RR = 0.69) declined. The prevalence of unmet need for healthcare significantly increased from 10.0% to 21.9% (RR = 2.10) and the proportion of people paying out-of-pocket for healthcare from 34.4% to 58.7% (RR = 1.69) between 2010 and 2015. The impact of the economic crisis in Greece on health was more nuanced than previous reports suggest. Effective strategies to mitigate the adverse health impacts of economic crises need to be better understood and implemented.

  • Journal article
    Seferidi P, Millett C, Laverty AA, 2017,

    Sweetened beverage intake in association to energy and sugar consumption and cardiometabolic markers in children

    , Pediatric Obesity, Vol: 13, Pages: 1-9, ISSN: 2047-6310

    BackgroundArtificially sweetened beverages (ASBs) are promoted as healthy alternatives to sugar‐sweetened beverages (SSBs) in order to reduce sugar intake, but their effects on weight control and glycaemia have been debated. This study examines associations of SSBs and ASBs with energy and sugar intake and cardiometabolic measures.MethodsOne thousand six hundred eighty‐seven children aged 4–18 participated in the National Diet and Nutrition Survey Rolling Programme (2008/9–2011/12) in the UK. Linear regression was used to examine associations between SSBs and ASBs and energy and sugar, overall and from solid foods and beverages, and body mass index, waist‐to‐hip ratio and blood analytes. Fixed effects linear regression examined within‐person associations with energy and sugar.ResultsCompared with non‐consumption, SSB consumption was associated with higher sugar intake overall (6.1%; 4.2, 8.1) and ASB consumption with higher sugar intake from solid foods (1.7%; 0.5, 2.9) but not overall, mainly among boys. On SSB consumption days, energy and sugar intakes were higher (216 kcal; 163, 269 and 7.0%; 6.2, 7.8), and on ASB consumption days, sugar intake was lower (−1.0%; −1.8, −0.1) compared with those on non‐consumption days. SSB and ASB intakes were associated with higher levels of blood glucose (SSB: 0.30 mmol L−1; 0.11, 0.49 and ASB: 0.24 mmol L−1; 0.06, 0.43) and SSB intake with higher triglycerides (0.29 mmol L−1; 0.13, 0.46). No associations were found with other outcomes.ConclusionSugar‐sweetened beverage intake was associated with higher sugar intake and both SSBs and ASBs with a less healthy cardiometabolic profile. These findings add to evidence that health policy should discourage all sweetened beverage consumption.

  • Journal article
    Zahid R, Dogar O, Mansoor S, Khan A, Kanaan M, Jawad M, Ahluwalia JS, Siddiqi Ket al., 2017,

    The efficacy of varenicline in achieving abstinence among waterpipe tobacco smokers - study protocol for a randomized controlled trial

    , Trials, Vol: 18, ISSN: 1745-6215

    Background:Waterpipe tobacco smoking has increased among youth across the globe including in the US, and it continues as a common and traditional form of smoking tobacco in Pakistan. A range of behavioral and pharmacological therapies are available to support people in quitting cigarette smoking; however, little evidence exists for the efficacy of these therapies in achieving abstinence among waterpipe tobacco smokers. The objective of this study is to assess the efficacy of varenicline when added to behavioral support for waterpipe tobacco smoking cessation, by measuring biochemically validated continuous abstinence in waterpipe tobacco smokers.Methods/design:This is a two-arm, double-blind, placebo-controlled randomized trial conducted in four districts in Punjab, Pakistan. Study participants include adults using a waterpipe (with or without concomitant cigarette, bidi or other forms of tobacco smoking) on a daily basis for at least 6 months and who are willing to quit. We will individually randomize 510 participants to one of the two arms of the trial. Participants in the intervention arm will receive varenicline and behavioral support and those in the control arm will receive placebo and behavioral support. The primary outcome will be continuous abstinence for at least 6 months (week 25) which is biochemically verified by a carbon monoxide level of <10 ppm. Secondary outcomes will include biochemically verified 7-day point abstinence at 5, 12 and 25 weeks and any lapses and relapses between the different assessment points. Tertiary outcomes will include assessment of withdrawal symptoms using the Mood and Physical Symptoms Scale (MPSS), smoking dependency using the Lebanon Waterpipe Dependency Scale (LWDS-11) and monitoring adverse outcomes.Discussion:This is an efficacy trial and would require a subsequent effectiveness trial for a definitive evaluation of the intervention.

  • Journal article
    Borges MC, Louzada ML, de Sá TH, Laverty AA, Parra DC, Garzillo JM, Monteiro CA, Millett Cet al., 2017,

    Artificially sweetened beverages and the response to the global obesity crisis

    , Plos Medicine, Vol: 14, ISSN: 1549-1676

    In March 2015, the World Health Organization (WHO) published revised guidelines onsugar intake that call on national governments to institute policies to reduce sugarintake and increase the scope for regulation of sugar-sweetened beverages (SSBs).• In face of the growing threat of regulatory action on SSBs, transnational beverage companiesare responding in multiple ways, including investing in the formulation and salesof artificially sweetened beverages (ASBs), promoted as healthier alternatives to SSBs.• The absence of consistent evidence to support the role of ASBs in preventing weightgain and the lack of studies on other long-term effects on health strengthen the positionthat ASBs should not be promoted as part of a healthy diet.• The promotion of ASBs must be discussed in a broader context of the additional potentialimpacts on health and the environment. In addition, a more robust evidence base,free of conflicts of interest, is needed.

  • Journal article
    Filippidis F, Gerovasili V, Man W, Quint JKet al., 2016,

    Trends in mortality from respiratory system diseases in Greece during the financial crisis

    , European Respiratory Journal, Vol: 48, Pages: 1487-1489, ISSN: 1399-3003
  • Journal article
    Hone T, Palladino R, Filippidis FT, 2016,

    Association of searching for health-related information online with self-rated health in the European Union.

    , Eur J Public Health, Vol: 26, Pages: 748-753

    BACKGROUND: The Internet is widely accessed for health information, but poor quality information may lead to health-worsening behaviours (e.g. non-compliance). Little is known about the health of individuals who use the Internet for health information. METHODS: Using the Flash Eurobarometer survey 404, European Union (EU) citizens aged ≥15 (n = 26 566) were asked about Internet utilisation for health information ('general' or 'disease-specific'), the sources used, self-rated health, and socioeconomic variables. Multivariable logistic regression was employed to assess the likelihood of bad self-rated health and accessing different health information sources (social networks, official website, online newspaper, dedicated websites, search engines). RESULTS: Those searching for general information were less likely to report bad health [odds ratios (OR) = 0.80; 95% confidence intervals (CI): 0.70-0.92], whilst those searching for disease-specific information were more likely (OR = 1.22; 95% CI: 1.07-1.38). Higher education and frequent doctor visits were associated with use of official websites and dedicated apps for health. Variation between EU member states in the proportion of people who had searched for general or disease-specific information online was high. CONCLUSIONS: Searching for general health information may be more conducive to better health, as it is easier to understand, and those accessing it may already be or looking to lead healthier lives. Disease-specific information may be harder to understand and assimilate into appropriate care worsening self-rated health. It may also be accessed if health services fail to meet individuals' needs, and health status is currently poor. Ensuring individuals' access to quality health services and health information will be key to addressing inequalities in health.

  • Journal article
    Filippidis FT, Mian SS, Millett C, 2016,

    Perceptions of quality and safety and experience of adverse events in 27 European Union healthcare systems, 2009-2013

    , International Journal for Quality in Health Care, Vol: 28, Pages: 721-727, ISSN: 1464-3677

    OBJECTIVE: To assess trends in the perception of quality and safety between 2009 and 2013 in the European Union (EU). DESIGN: We analysed data from waves 72.2 and 80.2 of the Eurobarometer survey. Multilevel logistic regression models adjusted for sociodemographic factors and country-level health expenditure were fitted to assess changes between 2009 and 2013 in each of the assessed outcomes. SETTING: Twenty-seven EU member states. PARTICIPANTS: A total of n = 26 663 (2009) and n = 26 917 (2013) individuals aged ≥15 years. MAIN OUTCOME MEASURES: Outcomes included the perception of being harmed in hospital and non-hospital care; rating of the overall quality of the healthcare system; and personal or family experience of adverse events. RESULTS: Respondents in 2013 were more likely to think that it was likely to be harmed in hospital (Odds Ratio [OR] = 1.09; 95% Confidence Interval [CI]: 1.05-1.13; P < 0.001) and non-hospital care (OR = 1.11; 95% CI: 1.07-1.15; P < 0.001), compared to 2009. However, they were more likely to rate the quality of their country's healthcare system as good (OR = 1.26; 95% CI: 1.21-1.32; P < 0.001) and no significant change over time was identified in reported experience of adverse events (OR = 1.00; 95% CI: 0.95-1.05; P = 0.929). Lower health expenditure and decrease in health expenditure between the two waves were associated with worse outcomes in overall quality and perceptions of harm. There was significant variation between and within countries in all indicators. CONCLUSIONS: The public's perception of safety in European healthcare systems declined in recent years, which highlights that there are safety issues that could be addressed.

  • Journal article
    Palladino R, Lee JT, Hone T, Filippidis FT, Millett Cet al., 2016,

    The Great Recession And Increased Cost Sharing In European Health Systems.

    , Health Aff (Millwood), Vol: 35, Pages: 1204-1213

    European health systems are increasingly adopting cost-sharing models, potentially increasing out-of-pocket expenditures for patients who use health care services or buy medications. Government policies that increase patient cost sharing are responding to incremental growth in cost pressures from aging populations and the need to invest in new health technologies, as well as to general constraints on public expenditures resulting from the Great Recession (2007-09). We used data from the Survey of Health, Ageing and Retirement in Europe to examine changes from 2006-07 to 2013 in out-of-pocket expenditures among people ages fifty and older in eleven European countries. Our results identify increases both in the proportion of older European citizens who incurred out-of-pocket expenditures and in mean out-of-pocket expenditures over this period. We also identified a significant increase over time in the percentage of people who incurred catastrophic health expenditures (greater than 30 percent of the household income) in the Czech Republic, Italy, and Spain. Poorer populations were less likely than those in the highest income quintile to incur an out-of-pocket expenditure and reported lower mean out-of-pocket expenditures, which suggests that measures are in place to provide poorer groups with some financial protection. These findings indicate the substantial weakening of financial protection for people ages fifty and older in European health systems after the Great Recession.

  • Journal article
    Filippidis FT, Laverty AA, Gerovasili V, Vardavas CIet al., 2016,

    Two year trends and predictors of e-cigarette use in 27 European Union member states

    , Tobacco Control, Vol: 26, Pages: 98-104, ISSN: 0964-4563

    Objective: This study assessed changes in levels of ever use, perceptions of harm from e-cigarettes and socio-demographic correlates of use among EU adults during 2012-2014, as well as determinants of current use in 2014. Methods: We analysed data from the 2012 (n=26,751) and 2014 (n=26,792) waves of the adult Special Eurobarometer for Tobacco survey. Point prevalence of current and ever use were calculated and logistic regression assessed correlates of current use and changes in ever use and perception of harm. Correlates examined included age, gender, tobacco smoking, education, area of residence, difficulties in paying bills and reasons for trying an e-cigarette. Results: The prevalence of ever use of e-cigarettes increased from 7.2% in 2012 to 11.6% in 2014 (Adjusted Odds Ratio [aOR]=1.91). EU-wide coefficient of variation in ever e-cigarette use was 42.1% in 2012 and 33.4% in 2014. The perception that e-cigarettes are harmful increased from 27.1% in 2012 to 51.6% in 2014 (aOR=2.99), but there were major differences in prevalence and trends between member states. Among those who reported that they had ever tried an e-cigarette in the 2014 survey, 15.3% defined themselves as current users. Those who tried an e-cigarette to quit smoking were more likely to be current users (aOR=2.82).Conclusion: Ever use of e-cigarettes increased during 2012-2014. People who started using e-cigarettes to quit smoking tobacco were more likely to be current users, but the trends vary by country. These findings underscore the need for more research into factors influencing e-cigarette use and its potential benefits and harms.

  • Journal article
    Webb E, Laverty A, Mindell J, Millett Cet al., 2016,

    Free Bus Travel and Physical Activity, Gait Speed, and Adiposity in the English Longitudinal Study of Ageing

    , American Journal of Public Health, Vol: 106, Pages: 136-142, ISSN: 1541-0048

    Objectives. We investigated associations between having a bus pass, enabling free local bus travel across the United Kingdom for state pension–aged people, and physical activity, gait speed, and adiposity.Methods. We used data on 4650 bus pass–eligible people (aged ≥ 62 years) at wave 6 (2012–2013) of the English Longitudinal Study of Ageing in regression analyses.Results. Bus pass holders were more likely to be female (odds ratio [OR] = 1.67; 95% confidence interval [CI] = 1.38, 2.02; P < .001), retired (OR = 2.65; 95% CI = 2.10, 3.35; P < .001), without access to a car (OR = 2.78; 95% CI = 1.83, 4.21; P < .001), to use public transportation (OR = 10.26; 95% CI = 8.33, 12.64; P < .001), and to be physically active (OR = 1.43; 95% CI = 1.12, 1.84; P = .004). Female pass holders had faster gait speed (b = 0.06 meters per second; 95% CI = 0.02, 0.09; P = .001), a body mass index 1 kilogram per meter squared lower (b = –1.20; 95% CI = –1.93, –0.46; P = .001), and waist circumference 3 centimeters smaller (b = –3.32; 95% CI = –5.02, –1.62; P < .001) than women without a pass.Conclusions. Free bus travel for older people helps make transportation universally accessible, including for those at risk for social isolation. Those with a bus pass are more physically active. Among women in particular, the bus pass is associated with healthier aging.

  • Journal article
    Lee T, Millett, 2015,

    Impact of noncommunicable disease multimorbidity onhealthcare utilisation and out-of-pocket expenditures in middle-income countries: cross sectional analysis

    , PLOS One, Vol: 10, ISSN: 1932-6203

    BackgroundThe burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa.MethodsSecondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007–2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models.ResultsThe prevalence of multimorbidity in the adult population varied from 3∙9% in Ghana to 33∙6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0∙56, 95% CI = 0∙46, 0∙66), a higher likelihood of being hospitalised in India (AOR = 1∙59, 95% CI = 1∙45, 1∙75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88∙3% for outpatient, 55∙9% for inpatient visit in China) in most countries.ConclusionMultimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups su

  • Journal article
    Chang K, Soljak MA, Lee T, Woringer, Johnston, Khunti K, Majeed, Millettet al., 2015,

    Coverage of a national cardiovascular risk assessment and management programme (NHS Health Check): Retrospective database study

    , Preventive Medicine, Vol: 78, ISSN: 1096-0260
  • Journal article
    Laverty AA, Palladino R, Lee JT, Millett Cet al., 2015,

    Associations between active travel and weight, blood pressure and diabetes in six middle income countries: a cross-sectional study in older adults

    , International Journal of Behavioral Nutrition and Physical Activity, Vol: 12, ISSN: 1479-5868
  • Journal article
    Jawad M, Lee JT, Millett C, 2015,

    Waterpipe Tobacco Smoking Prevalence and Correlates in 25 Eastern Mediterranean and Eastern European Countries: Cross-Sectional Analysis of the Global Youth Tobacco Survey

    , Nicotine & Tobacco Research, Vol: 18, Pages: 395-402, ISSN: 1469-994X

    Introduction: Waterpipe tobacco smoking is highly prevalent among young people in some settings. There is an absence of nationally representative prevalence studies of waterpipe tobacco use and dual use with other tobacco products in young people.Methods: We conducted a secondary analysis of the Global Youth Tobacco Survey, a nationally representative cross-sectional study of students aged 13–15 years. Of 180 participating countries, 25 included optional waterpipe tobacco smoking questions: 15 Eastern Mediterranean and 10 Eastern European countries. We calculated the prevalence of current (past 30-day) waterpipe tobacco use, including dual waterpipe and other tobacco use, and used logistic regression models to identify sociodemographic correlates of waterpipe tobacco smoking. Individual country results were combined in a random effects meta-analysis.Results: Waterpipe tobacco smoking prevalence was highest in Lebanon (36.9%), the West Bank (32.7%) and parts of Eastern Europe (Latvia 22.7%, the Czech Republic 22.1%, Estonia 21.9%). These countries also recorded greater than 10% prevalence of dual waterpipe and cigarette use. In a meta-analysis, higher odds of waterpipe tobacco smoking were found among males (Adjusted odds ratio [AOR] = 1.37, 95% confidence interval [CI] = 1.18% to 1.59%), cigarette users (AOR = 6.95, 95% CI = 5.74% to 8.42%), those whose parents (AOR = 1.54, 95% CI = 1.31% to 1.82%) or peers smoked (AOR = 3.53, 95% CI = 2.97% to 4.20%) and those whose parents had higher educational attainment (Father, AOR = 1.47, 95% CI = 1.14% to 1.89%; Mother, AOR = 1.62, 95% CI = 1.07% to 2.46%). We report on regional- and country income-level differences.Conclusions: Waterpipe tobacco smoking, including dual waterpipe and cigarette use, is alarmingly high in several Eastern Mediterranean and Eastern European countries. Ongoing waterpipe tobacco smoking surveillance is warranted.

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