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  • Journal article
    Hone T, Gomez S, Rao M, Ferreira A, Barkley S, Swift Koller Tet al., 2022,

    Primary Health care as a platform for addressing racial discrimination to “leave no one behind” and reduce health inequities

    , International Journal for Equity in Health, Vol: 21, ISSN: 1475-9276

    The health inequities faced by populations experiencing racial discrimination, including indigenous peoples and people of African descent, Roma, and other ethnic minorities, are an issue of global concern. Health systems have an important role to play in tackling these health inequities. Health systems based on comprehensive Primary Health Care (PHC) are best placed to tackle health inequities because PHC encompasses a whole-of-society approach to health. PHC includes actions to address the wider social determinants of health, multisectoral policy and action, intercultural and integrated healthcare services, community empowerment, and a focus on addressing health inequities. PHC can also serve as a platform for introducing specific actions to tackle racial discrimination and can act to drive wider societal change for tackling racial and ethnic health inequities.

  • Journal article
    Chang K, Khandpur N, Neri D, Touvier M, Huybrechts I, Millett C, Vamos Eet al., 2021,

    Association between childhood consumption of ultraprocessed food and adiposity trajectories in the Avon Longitudinal Study of Parents and Children birth cohort

    , JAMA Pediatrics, Vol: 175, ISSN: 2168-6211

    Importance Reports of associations between higher consumption of ultraprocessed foods (UPF) and elevated risks of obesity, noncommunicable diseases, and mortality in adults are increasing. However, associations of UPF consumption with long-term adiposity trajectories have never been investigated in children.Objective To assess longitudinal associations between UPF consumption and adiposity trajectories from childhood to early adulthood.Design, Setting, and Participants This prospective birth cohort study included children who participated in the Avon Longitudinal Study of Parents and Children (ALSPAC) in Avon County, southwest England. Children were followed up from 7 to 24 years of age during the study period from September 1, 1998, to October 31, 2017. Data were analyzed from March 1, 2020, to January 31, 2021.Exposures Baseline dietary intake data were collected using 3-day food diaries. Consumption of UPF (applying the NOVA food classification system) was computed as a percentage of weight contribution in the total daily food intake for each participant and categorized into quintiles.Main Outcomes and Measures Repeated recordings of objectively assessed anthropometrics (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared], weight, and waist circumference) and dual-energy x-ray absorptiometry measurements (fat and lean mass indexes [calculated as fat and lean mass, respectively, divided by height in meters squared] and body fat percentage). Associations were evaluated using linear growth curve models and were adjusted for study covariates.Results A total of 9025 children (4481 [49.7%] female and 4544 [50.3%] male) were followed up for a median of 10.2 (interquartile range, 5.2-16.4) years. The mean (SD) UPF consumption at baseline was 23.2% (5.0%) in quintile 1, 34.7% (2.5%) in quintile 2, 43.4% (2.5%) in quintile 3, 52.7% (2.8%) in quintile 4, and 67.8% (8.1%) in quintile 5. Among those in the highest quintile of UPF

  • Journal article
    Alves LC, Sanchez MN, Hone T, Pinto LF, Nery JS, Tauil PL, Barreto ML, Penna GOet al., 2021,

    The association between a conditional cash transfer programme and malaria incidence: a longitudinal ecological study in the Brazilian Amazon between 2004 and 2015

    , BMC Public Health, Vol: 21, Pages: 1-9, ISSN: 1471-2458

    BackgroundMalaria causes 400 thousand deaths worldwide annually. In 2018, 25% (187,693) of the total malaria cases in the Americas were in Brazil, with nearly all (99%) Brazilian cases in the Amazon region. The Bolsa Família Programme (BFP) is a conditional cash transfer (CCT) programme launched in 2003 to reduce poverty and has led to improvements in health outcomes. CCT programmes may reduce the burden of malaria by alleviating poverty and by promoting access to healthcare, however this relationship is underexplored. This study investigated the association between BFP coverage and malaria incidence in Brazil.MethodsA longitudinal panel study was conducted of 807 municipalities in the Brazilian Amazon between 2004 and 2015. Negative binomial regression models adjusted for demographic and socioeconomic covariates and time trends were employed with fixed effects specifications.ResultsA one percentage point increase in municipal BFP coverage was associated with a 0.3% decrease in the incidence of malaria (RR = 0.997; 95% CI = 0.994–0.998). The average municipal BFP coverage increased 24 percentage points over the period 2004–2015 corresponding to be a reduction of 7.2% in the malaria incidence.ConclusionsHigher coverage of the BFP was associated with a reduction in the incidence of malaria. CCT programmes should be encouraged in endemic regions for malaria in order to mitigate the impact of disease and poverty itself in these settings.

  • Journal article
    Rauber F, Chang K, Vamos EP, da Costa Louzada ML, Monteiro CA, Millett C, Levy RBet al., 2021,

    Ultra-processed food consumption and risk of obesity: a prospective cohort study of UK Biobank

    , EUROPEAN JOURNAL OF NUTRITION, Vol: 60, Pages: 2169-2180, ISSN: 1436-6207
  • Journal article
    Levy RB, Rauber F, Chang K, Louzada MLDC, Monteiro CA, Millett C, Vamos EPet al., 2021,

    Ultra-processed food consumption and type 2 diabetes incidence: A prospective cohort study.

    , Clinical Nutrition, Vol: 40, Pages: 3608-3614, ISSN: 0261-5614

    BACKGROUND: Ultra-processed foods account for more than 50% of daily calories consumed in several high-income countries, with sales of ultra-processed foods soaring globally, especially in middle-income countries. The objective of this study is to investigate the association between ultra-processed food (UPF) consumption and risk of type 2 diabetes (T2D) in a UK-based prospective cohort study. METHODS: Participants of the UK Biobank (2007-2019) aged 40-69 years without diabetes at recruitment who provided 24-h dietary recall and follow-up data were included. UPFs were defined using the NOVA food classification. Multivariable Cox proportional hazards regression models were used to evaluate the association between UPF consumption and the risk of T2D adjusting for socio-demographic, anthropometric and lifestyle characteristics. RESULTS: A total of 21,730 participants with a mean age of 55.8 years and mean UPF intake of 22.1% at baseline were included. During a mean follow-up of 5.4 years (116,956 person-years), 305 incident T2D cases were identified. In the fully adjusted model, compared with the group in the lowest quartile of UPF intake, the hazard ratio for T2D was 1.44, 1.04-2.02 in the group with the highest quartile of UPF consumption. A gradient of elevated risk of T2D associated with increasing quartiles of UPF intake was consistently observed (p value for trend < 0.028). A significantly increased risk of T2D was observed per 10 percentage points increment in UPF consumption ([adjusted HR]: 1.12, 95% confidence interval [CI]: 1.04-1.20). CONCLUSIONS: Our findings demonstrate that a diet high in UPFs is associated with a clinically important increased risk of T2D. Identifying and implementing effective public health actions to reduce UPF consumption in the UK and globally are urgently required.

  • Journal article
    Laverty A, Millett C, Filippidis FT, 2020,

    Associations between cigarette prices and consumption in Europe 2004 - 2014

    , Tobacco Control, Vol: 30, Pages: 111-113, ISSN: 0964-4563

    IntroductionWhile tobacco price increases are known to reduce smoking prevalence, these relationships may be blunted by the availability of budget cigarettes, promoted by the tobacco industry to maintain profits. There has been limited previous research on the impact of budget cigarettes on cigarette consumption and used data from Europe 2004-2014 to investigate this.MethodsAnnual population-weighted cigarette consumption per adult data come from the International Cigarette Consumption Database. Annual tobacco price data come from Euromonitor International for 23 European countries. We examined median prices as well as price differentials, operationalised as percentages obtained by dividing the difference between median and minimum prices by median price. We used a linear random-effects model to assess associations between these and cigarette consumption within-year and with a one-year time lag.ResultsCigarette consumption per capita has declined over the study period (-29.5 cigarettes per capita per year, 95% Confidence Intervals -46.8 to -12.1). Our analysis suggests that increases in cigarette price differentials, a marker of opportunities for smokers to switch to less expensive cigarettes, are associated with greater consumption in the same year (+6.4 for a 10% increase in differential, -40.0 to 52.6) and are associated with greater consumption the following year (+67.6, 25.8 to 109.5). ConclusionThese analyses suggest that even in Europe where tobacco taxes are relatively high compared with other regions, differential cigarette pricing strategies may undermine tobacco control. Further research is needed on links between tobacco price structures and consumption and policy design to maximise the effectiveness of tobacco tax.

  • Journal article
    Filippidis F, Chang C-M, Blackmore I, Laverty Aet al., 2020,

    Prices and illicit trade of cigarettes in the European Union, a cross-sectional analysis

    , Nicotine and Tobacco Research, Vol: 22, Pages: 2271-2275, ISSN: 1462-2203

    IntroductionWithin the context of the World Health Organization Framework Convention on Tobacco Control Protocol to Eliminate Illicit Trade in Tobacco Products and the impending revision of the EU directive on tobacco excise rules we assessed whether cigarettes price is linked to being offered illicit cigarettes.MethodsWe combined data being offered illicit cigarettes from the 2015 Special Eurobarometer Survey on Illicit Tobacco (N=27,672) with area-level data on Gross Domestic Product, unemployment, perceived corruption and sharing a border with a non-European Economic Area (non-EEA) state. We used the 2015 Weighted Average Price of cigarettes (WAP), which reflects the average price of a cigarette pack in each member state. We assessed associations between prices and illicit trade using 3-level ordered regression models.Results19.6% of respondents reported ever being offered illicit cigarettes, 6.4% repeatedly. In fully adjusted models WAP was not associated with being more likely to have been offered illicit market cigarettes more often (adjusted Odds Ratio=1.02, 95% Confidence Interval 0.91; 1.15). Sharing a border with a non-EEA member state was associated with increased likelihood of reporting being offered illicit cigarettes more often (1.73, 1.26;2.39).ConclusionThis study found no significant association between cigarette prices and reporting being offered illicit cigarettes; sharing a border with a non-EEA member state was linked to illicit trade. This study adds to evidence that increasing prices of cigarettes are not associated with illicit trade and that the focus should remain on securing supply chains, including through features such independent traceability systems.ImplicationsAfter adjusting for individual and regional factors, we did not identify an association between prices of cigarettes and likelihood of reporting being offered illicit cigarettes in the EU. Sharing a border with a non-EEA state however, was associated with increased likelihood of

  • Journal article
    Paes-Sousa R, Millett C, Rocha R, Barreto ML, Hone Tet al., 2020,

    Science misuse and polarised political narratives in the COVID-19 response

    , The Lancet, Vol: 396, Pages: 1635-1636, ISSN: 0140-6736
  • Journal article
    Hone T, Saraceni V, Coeli CM, Trajman A, Rasella D, Millett C, Durovni Bet al., 2020,

    Primary health care expansion and mortality in Brazil’s urban poor: a cohort analysis of 1.2 million adults

    , PLoS Medicine, Vol: 17, Pages: 1-20, ISSN: 1549-1277

    BackgroundExpanding delivery of primary health care to urban poor populations is a priority in many low-and middle-income countries. This remains a key challenge in Brazil despite expansion of the country’s internationally recognised Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil since 2008. Methods and FindingsA cohort of 1,241,351 million low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilisation and mortality records was analysed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and non-users. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA).The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education whilst 102,899 (8%) had no formal education. Two-thirds of individuals (827250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analysed of which 8,765 (26%) were due to cardiovascular disease, 5,777 (17%) due to neoplasms, 5,683 (17%) due to external causes, 3,152 (9%) due to respiratory diseases, and 3,115 (9%) due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95%CI: 0.54 to 0.59, p<0.001) and a five-year risk reduction of 8.3 per 1000 (95%CI: 7.8 to 8.9, p<0.001) compared to a non-FHS user. There were greater reductions in the risk of death for FHS users who: were black (HR:0.50 (95%CI: 0.46 to 0.54, p<0.001)) or pardo (HR:0.57 (95%CI: 0.54 to 0.60, p<0.001) compared to white (HR:0.59 (95%CI: 0.56 to 0.63, p<0.001); had lower educational attainment

  • Journal article
    Hone T, Powell-Jackon T, Santos LMP, Soares RDS, Proenço de Oliveira F, Niskier Sanchez M, Harris M, Santos F, Millett Cet al., 2020,

    Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities

    , BMC Health Services Research, Vol: 20, ISSN: 1472-6963

    BackgroundInvesting in human resources for health (HRH) is vital for achieving universal health care and the Sustainable Development Goals. The Programa Mais Médicos (PMM) (More Doctors Programme) provided 17,000 doctors, predominantly from Cuba, to work in Brazilian primary care. This study assesses whether PMM doctor allocation to municipalities was consistent with programme criteria and associated impacts on amenable mortality.MethodsDifference-in-differences regression analysis, exploiting variation in PMM introduction across 5565 municipalities over the period 2008–2017, was employed to examine programme impacts on doctor density and mortality amenable to healthcare. Heterogeneity in effects was explored with respect to doctor allocation criteria and municipal doctor density prior to PMM introduction.ResultsAfter starting in 2013, PMM was associated with an increase in PMM-contracted primary care doctors of 15.1 per 100,000 population. However, largescale substitution of existing primary care doctors resulting in a net increase of only 5.7 per 100,000. Increases in both PMM and total primary care doctors were lower in priority municipalities due to lower allocation of PMM doctors and greater substitution effects. The PMM led to amenable mortality reductions of − 1.06 per 100,000 (95%CI: − 1.78 to − 0.34) annually – with greater benefits in municipalities prioritised for doctor allocation and where doctor density was low before programme implementation.ConclusionsPMM potential health benefits were undermined due to widespread allocation of doctors to non-priority areas and local substitution effects. Policies seeking to strengthen HRH should develop and implement needs-based criteria for resource allocation.

  • Journal article
    Jawad M, Hone T, Vamos E, Roderick P, Sullivan R, Millett Cet al., 2020,

    Estimating indirect mortality impacts of armed conflict in civilian populations: panel regression analyses of 193 countries, 1990-2017

    , BMC Medicine, Vol: 266, Pages: 1-11, ISSN: 1741-7015

    BackgroundArmed conflict can indirectly affect population health through detrimental impacts on political and social institutions and destruction of infrastructure. This study aimed to quantify indirect mortality impacts of armed conflict in civilian populations globally, and explore differential effects by armed conflict characteristics and population groups.Methods We included 193 countries between 1990 and 2017 and constructed fixed effects panel regression models using data from the Uppsala Conflict Data Program and Global Burden of Disease study. Mortality rates were corrected to exclude battle-related deaths. We assessed separately four different armed conflict variables (capturing binary, continuous, categorical and quintile exposures) and ran models by cause-specific mortality stratified by age groups and sex. Post-estimation analyses calculated the number of civilian deaths. ResultsWe identified 1,118 unique armed conflicts. Armed conflict was associated with increases in civilian mortality - driven by conflicts categorised as wars. Wars were associated with an increase in age-standardised all-cause mortality of 81.5 per 100.000 population (β 81.5, 95% CI 14.3-148.8) in adjusted models contributing 29.4 million civilian deaths (95% CI 22.1-36.6) globally over the study period. Mortality rates from communicable, maternal, neonatal, and nutritional diseases (β 51.3, 95% CI 2.6-99.9), non-communicable diseases (β 22.7, 95% CI 0.2-45.2) and injuries (β 7.6, 95% CI 3.4-11.7) associated with war increased, contributing 21.0 million (95% CI 16.3-25.6), 6.0 million (95% CI 4.1-8.0), and 2.4 million deaths (95% CI 1.7-3.1) respectively. War-associated increases in all-cause and cause-specific mortality were found across all age groups and both genders, but children aged 0-5 years had the largest relative increases in mortality. Conclusions Armed conflict, particularly war, is associated with a substantial indirect mortality impact among civilians

  • Journal article
    Jawad M, Blanchet K, Leaning J, 2020,

    Editorial: Revisiting public health response in times of war

    , JOURNAL OF PUBLIC HEALTH, Vol: 42, Pages: E285-E286, ISSN: 1741-3842
  • Journal article
    van Schalkwyk M, McKee M, Been J, Millett C, Filippidis Fet al., 2020,

    Size matters: an analysis of cigarette pack sizes across 23 European Union countries using Euromonitor data, 2006 to 2017

    , PLoS One, Vol: 15, ISSN: 1932-6203

    IntroductionThe tobacco industry (TI) has used small cigarette pack sizes to encourage brand-switching and consumption, and to mitigate the impacts of tobacco tax increases. Since 2016, the European Union (EU) Tobacco Products Directive (TPD) specifies a minimum pack size of 20 cigarettes. We examined cigarette pack sizes in the EU and whether pack size composition differed between cheap and expensive price segments, as well as the impact of the revised TPD.MethodsWe conducted a longitudinal analysis of pricing data from 23 EU countries between 2006–2017. We examined pack sizes over time to assess the impact of the TPD, differences in pack size composition between cheap and expensive price segments, and compared gaps in median prices between products using actual and ‘expected’ prices (price if all packs contained 20 sticks).ResultsCigarette pack sizes changed over time, across the EU. The distribution of pack sizes varied between price segments, with small pack sizes especially frequent in the cheap segment of the cigarette market, but this varied over time and across countries. Packs of <20 cigarettes almost disappeared from the data samples after implementation of the TPD.ConclusionImplementation of the TPD appears to have virtually eliminated packs with <20 cigarettes, restricting their use by the TI. Our analysis suggests pack sizes have been used differentially across the EU. Country-level analyses on the industry’s use of pack sizes, consumer responses, and evaluations of restricting certain pack sizes are needed to confirm our findings and strengthen policy.

  • Journal article
    Crookes C, Palladino R, Seferidi P, Hirve R, Siskou O, Filippidis Fet al., 2020,

    The impact of the economic crisis on household health expenditure in Greece: an interrupted time series analysis

    , BMJ Open, Vol: 10, Pages: 1-11, ISSN: 2044-6055

    Objectives and setting The 2008 financial crisis had a particularly severe impact onGreece. To contain spending, the government capped public health expenditure andintroduced increased cost-sharing. The Greek case is important for studying theimpact of recessions on health systems. This study analysed changes in householdhealth expenditure in Greece over the economic crisis and explored whether theimpact differed across socioeconomic groups.Participants We used data from the Greek Household Budget Survey for the years2004 and 2008-2017. The dataset comprised 51,654 households, with a total of128,111 members.Design We compared pre- and post-crisis trends in Greek household out-of-pocketpayments for healthcare from 2004-2017 using an interrupted time series analysis.This study explored spending in Euros and as a share of total household purchases.Results Our results indicated that the population level trend in household healthspending was reversed after the crisis began (pre-crisis trend:€0.040 decrease perquarter (95% CI: -0.785 to -0.022), post-crisis trend:€0.315 increase per quarter(95% CI: -0.004 to 0.635)). We also found that spending on inpatient services andpharmaceuticals has been increasing since the start of the crisis, whereas outpatientservices expenditure has been decreasing. Across all households, out-of-pocketpayments incurred a greater financial burden after the crisis relative to pre-existingtrends, but the poorest households incurred a disproportionately higher burden.Conclusions This was the first study to use an interrupted time series analysis toassess the impact of the economic crisis on household health expenditure in Greece.Our findings suggest that there was an erosion of financial protection for Greekhouseholds as a consequence of the economic crisis. This effect was particularlypronounced amongst poorer households, which is indicative of a regressivefinancing system.

  • Journal article
    Seferidi P, Laverty AA, Collins B, Bandosz P, Capewell S, O'Flaherty M, Millett C, Pearson-Stuttard Jet al., 2020,

    Potential impacts of post-Brexit agricultural policy on fruit and vegetable intake and cardiovascular disease in England: a modelling study

    , BMJ Nutrition, Prevention & Health, Vol: 3, ISSN: 2516-5542

    Background Current proposals for post-Brexit agricultural policy do not explicitly incorporate public health goals. The revised agricultural policy may be an opportunity to improve population health by supporting domestic production and consumption of fruits and vegetables (F&V). This study aims to quantify the potential impacts of a post-Brexit agricultural policy that increases land allocated to F&V on cardiovascular disease (CVD) mortality and inequalities in England, between 2021 to 2030.Methods We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to translate changes in land allocated to F&V into changes in F&V intake and associated CVD deaths, stratified by age, sex and Index of Multiple Deprivation. The model combined data on F&V agriculture, waste, purchases and intake, CVD mortality projections and appropriate relative risks. We modelled two scenarios, assuming that land allocated to F&V would gradually increase to 10% and 20% of land suitable for F&V production.Results We found that increasing land use for F&V production to 10% and 20% of suitable land would increase fruit intake by approximately 3.7% (95% uncertainty interval: 1.6% to 8.6%) and 17.4% (9.1% to 36.9%), and vegetable intake by approximately 7.8% (4.2% to 13.7%) and 37% (24.3% to 55.7%), respectively, in 2030. This would prevent or postpone approximately 3890 (1950 to 7080) and 18 010 (9840 to 28 870) CVD deaths between 2021 and 2030, under the first and second scenario, respectively. Both scenarios would reduce inequalities, with 16% of prevented or postponed deaths occurring among the least deprived compared with 22% among the most deprived.Conclusion Post-Brexit agricultural policy presents an important opportunity to improve dietary intake and associated cardiovascular mortality by supporting domestic production of F&V as part of a comprehensive strategy that intervenes across the supply chain.

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