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  • Journal article
    Habib RR, Ziadee M, Younes EA, Harastani H, Hamdar L, Jawad M, El Asmar Ket al., 2019,

    Displacement, deprivation and hard work among Syrian refugee children in Lebanon

    , BMJ GLOBAL HEALTH, Vol: 4, ISSN: 2059-7908
  • Journal article
    Seferidi P, Laverty A, Pearson-Stuttard J, Bandosz P, Collins B, Guzman-Castillo M, Capewell S, O'Flaherty M, Millett Cet al., 2019,

    Impacts of Brexit on fruit and vegetable intake and cardiovascular disease in England: a modelling study

    , BMJ Open, Vol: 9, ISSN: 2044-6055

    Objectives To estimate the potential impacts of different Brexit trade policy scenarios on the price and intake of fruits and vegetables (F&V) and consequent cardiovascular disease (CVD) deaths in England between 2021 and 2030.Design Economic and epidemiological modelling study with probabilistic sensitivity analysis.Setting The model combined publicly available data on F&V trade, published estimates of UK-specific price elasticities, national survey data on F&V intake, estimates on the relationship between F&V intake and CVD from published meta-analyses and CVD mortality projections for 2021–2030.Participants English adults aged 25 years and older.Interventions We modelled four potential post-Brexit trade scenarios: (1) free trading agreement with the EU and maintaining half of non-EU free trade partners; (2) free trading agreement with the EU but no trade deal with any non-EU countries; (3) no-deal Brexit; and (4) liberalised trade regime that eliminates all import tariffs.Outcome measures Cumulative coronary heart disease and stroke deaths attributed to the different Brexit scenarios modelled between 2021 and 2030.Results Under all Brexit scenarios modelled, prices of F&V would increase, especially for those highly dependent on imports. This would decrease intake of F&V between 2.5% (95% uncertainty interval: 1.9% to 3.1%) and 11.4% (9.5% to 14.2%) under the different scenarios. Our model suggests that a no-deal Brexit scenario would be the most harmful, generating approximately 12 400 (6690 to 23 390) extra CVD deaths between 2021 and 2030, whereas establishing a free trading agreement with the EU would have a lower impact on mortality, contributing approximately 5740 (2860 to 11 910) extra CVD deaths.Conclusions Trade policy under all modelled Brexit scenarios could increase price and decrease intake of F&V, generating substantial additional CVD mortality in England. The UK government should consider the population healt

  • Journal article
    Qin V, Hone T, Millett C, Moreno-Serra R, McPake B, Atun R, Lee TYet al., 2019,

    The impact of user charges on health outcomes in low-income and middle-income countries: a systematic review

    , BMJ Global Health, Vol: 3, ISSN: 2059-7908

    Background User charges are widely used health financing mechanisms in many health systems in low-income and middle-income countries (LMICs) due to insufficient public health spending on health. This study systematically reviews the evidence on the relationship between user charges and health outcomes in LMICs, and explores underlying mechanisms of this relationship.Methods Published studies were identified via electronic medical, public health, health services and economics databases from 1990 to September 2017. We included studies that evaluated the impact of user charges on health in LMICs using randomised control trial (RCT) or quasi-experimental (QE) study designs. Study quality was assessed using Cochrane Risk of Bias and Risk of Bias in Non-Randomized Studies—of Intervention for RCT and QE studies, respectively.Results We identified 17 studies from 12 countries (five upper-middle income countries, five lower-middle income countries and two low-income countries) that met our selection criteria. The findings suggested a modest relationship between reduction in user charges and improvements in health outcomes, but this depended on health outcomes measured, the populations studied, study quality and policy settings. The relationship between reduced user charges and improved health outcomes was more evident in studies focusing on children and lower-income populations. Studies examining infectious disease–related outcomes, chronic disease management and nutritional outcomes were too few to draw meaningful conclusions. Improved access to healthcare as a result of reduction in out-of-pocket expenditure was identified as the possible causal pathway for improved health.Conclusions Reduced user charges were associated with improved health outcomes, particularly for lower-income groups and children in LMICs. Accelerating progress towards universal health coverage through prepayment mechanisms such as taxation and insurance can lead to improved health outcomes

  • Journal article
    Pacheco Santos LM, Millett C, Rasella D, Hone Tet al., 2018,

    The end of Brazil's More Doctors programme? Those in greatest need will be hit hardest

    , BMJ, Vol: 363, ISSN: 0959-8138
  • Journal article
    Patterson R, Webb E, Mindell JS, Millett C, Laverty AAet al., 2018,

    Ethnic group differences in impacts of free bus passes in England: A national study

    , Journal of Transport and Health, Vol: 11, Pages: 1-14, ISSN: 2214-1405

    BackgroundA pass permitting free bus travel for older people (aged ≥60 years) in England was introduced in 2006. There has been no examination of whether this scheme has differential effects across ethnic groups. We examined whether Black and South Asian participants were more likely to hold a bus pass and have higher associated levels of active travel than White participants.MethodsData come from the National Travel Survey, a nationally representative sample of the travel patterns of households in England. Using cross-sectional data from 33,344 participants eligible for a bus pass 2006–2014, we investigated ethnic differences in bus pass uptake and associations with bus use, active travel and walking ≥3 times per week.ResultsBlack participants were more likely to hold a bus pass (84%) than South Asian or White participants (74% and 75% respectively). Black participants accumulated 56% of their active travel as part of bus journeys, compared with 29% in White and 44% in South Asian participants. Bus pass possession was associated with increased odds of bus-related active travel in all ethnic groups.ConclusionsThese findings suggest that the free bus pass scheme in England is associated with higher levels of active travel and that these may be greater among minority ethnic groups. Removing financial barriers to active travel could produce important health benefits particularly among ethnic minority groups, who have low levels of leisure-based physical activity.

  • Journal article
    Seferidi P, Laverty AA, Pearson-Stuttard J, Guzman-Castillo M, Collins B, Capewell S, OFlaherty M, Millett CJet al., 2018,

    Implications of Brexit on the effectiveness of the UK soft drinks industry levy upon coronary heart disease in England: a modelling study

    , Public Health Nutrition, Vol: 21, Pages: 3431-3439, ISSN: 1368-9800

    Objective:An industry levy on sugar-sweetened beverages (SSB) was implemented in the UK in 2018. One year later, Brexit is likely to change the UK trade regime with potential implications for sugar price. We modelled the effect of potential changes in sugar price due to Brexit on SSB levy impacts upon CHD mortality and inequalities.Design:We modelled a baseline SSB levy scenario; an SSB levy under ‘soft’ Brexit, where the UK establishes a free trading agreement with the EU; and an SSB levy under ‘hard’ Brexit, in which World Trade Organization tariffs are applied. We used the previously validated IMPACT Food Policy model and probabilistic sensitivity analysis to estimate the effect of each scenario on CHD deaths prevented or postponed and life-years gained, stratified by age, sex and socio-economic circumstance, in 2021.Setting:England.Subjects:Adults aged 25 years or older.Results:The SSB levy was associated with approximately 370 (95 % uncertainty interval 220, 560) fewer CHD deaths and 4490 (2690, 6710) life-years gained in 2021. Associated reductions in CHD mortality were 4 and 8 % greater under ‘soft’ and ‘hard’ Brexit scenarios, respectively. The SSB levy was associated with approximately 110 (50, 190) fewer CHD deaths in the most deprived quintile compared with 60 (20, 100) in the most affluent, under ‘hard’ Brexit.Conclusions:Our study found the SSB levy resilient to potential effects of Brexit upon sugar price. Even under ‘hard’ Brexit, the SSB levy would yield benefits for CHD mortality and inequalities. Brexit negotiations should deliver a fiscal and regulatory environment which promotes population health.

  • Journal article
    Basu S, Yudkin JS, Berkowitz SA, Jawad M, Millett Cet al., 2018,

    Reducing chronic disease through changes in food aid: A microsimulation of nutrition and cardiometabolic disease among Palestinian refugees in the Middle East

    , PLOS Medicine, Vol: 15

    BackgroundType 2 diabetes mellitus and cardiovascular disease and have become leading causes of morbidity and mortality among Palestinian refugees in the Middle East, many of whom live in long-term settlements and receive grain-based food aid. The objective of this study was to estimate changes in type 2 diabetes and cardiovascular disease morbidity and mortality attributable to a transition from traditional food aid to either (i) a debit card restricted to food purchases, (ii) cash, or (iii) an alternative food parcel with less grain and more fruits and vegetables, each valued at $30/person/month.Methods and findingsAn individual-level microsimulation was created to estimate relationships between food aid delivery method, food consumption, type 2 diabetes, and cardiovascular disease morbidity and mortality using demographic data from the United Nations (UN; 2017) on 5,340,443 registered Palestinian refugees in Syria, Jordan, Lebanon, Gaza, and the West Bank, food consumption data (2011–2017) from households receiving traditional food parcel delivery of food aid (n = 1,507 households) and electronic debit card delivery of food aid (n = 1,047 households), and health data from a random 10% sample of refugees receiving medical care through the UN (2012–2015; n = 516,386). Outcome metrics included incidence per 1,000 person-years of hypertension, type 2 diabetes, atherosclerotic cardiovascular disease events, microvascular events (end-stage renal disease, diabetic neuropathy, and proliferative diabetic retinopathy), and all-cause mortality. The model estimated changes in total calories, sodium and potassium intake, fatty acid intake, and overall dietary quality (Mediterranean Dietary Score [MDS]) as mediators to each outcome metric. We did not observe that a change from food parcel to electronic debit card delivery of food aid or to cash aid led to a meaningful change in consumption, biomarkers, or disease outcomes. By contrast, a shift to an alternative foo

  • Journal article
    Laverty AA, Filippidis FT, Vardavas C, 2018,

    Patterns, trends and determinants of e-cigarette use in 28 European Union Member States 2014-2017

    , Preventive Medicine, Vol: 116, Pages: 13-18, ISSN: 0091-7435

    There is a lack of nationally representative data on regular e-cigarette use, as well as on the transition from experimentation to regular use. This study examines changes in these in Europe between 2014 and 2017. Data come from the 2014 (n = 27,801) and 2017 (n = 27,901) adult Special Eurobarometer for Tobacco Survey, providing nationally representative surveys of 28 EU member states. We defined regular use of e-cigarettes as daily or weekly use from a question on frequency of e-cigarette use. Among ever users of e-cigarettes we assessed socio-demographic correlates of becoming a regular user. 1.5% of the EU population were regular e-cigarette users in 2014, which had risen to 1.8% in 2017. In 2017 63 million Europeans aged 15 or older had ever used e-cigarettes (95% CI, 59.9 million–66.2 million), and 7.6 million (95% CI, 6.5million–8.9 million) were regular e-cigarette users. Among those who had ever used e-cigarettes, participants aged 15–24 years were less likely to be regular user than those aged ≥55 years (16.9% vs. 38.1%), as were never smokers compared with current and former smokers (12.8% vs. 27.0% vs. 41.3%). The proportion of adults who were regular e-cigarette users in 2017 ranged from 4.7% in the UK to 0.2% in Bulgaria. There have been slight rises in the proportion of people regularly using e-cigarettes in the EU, and this varies considerably between member states, indicating the role of the regional environment in supporting or deterring e-cigarette use.

  • Journal article
    Jawad M, Lee JT, Glantz S, Millett Cet al., 2018,

    Price elasticity of demand of non-cigarette tobacco products: a systematic review and meta-analysis

    , Tobacco Control, Vol: 27, Pages: 689-695, ISSN: 0964-4563

    OBJECTIVE: To systematically review the price elasticity of demand of non-cigarette tobacco products. DATA SOURCES: Medline, Embase, EconLit and the Web of Science without language or time restrictions. STUDY SELECTION: Two reviewers screened title and abstracts, then full texts, independently and in duplicate. We based eligibility criteria on study design (interventional or observational), population (individuals or communities without geographic restrictions), intervention (price change) and outcome (change in demand). DATA EXTRACTION: We abstracted data on study features, outcome measures, statistical approach, and single best own- and cross-price elasticity estimates with respect to cigarettes. We conducted a random effects meta-analysis for estimates of similar product, outcome and country income level. For other studies we reported median elasticities by product and country income level. DATA SYNTHESIS: We analysed 36 studies from 15 countries yielding 125 elasticity estimates. A 10% price increase would reduce demand by: 8.3% for cigars (95% CI 2.9 to 13.8), 6.4% for roll your owns (95% CI 4.3 to 8.4), 5.7% for bidis (95% CI 4.3 to 7.1) and 2.1% for smokeless tobacco (95% CI -0.6 to 4.8). Median price elasticities for all ten products were also negative. Results from few studies that examined cross-price elasticity suggested a positive substitution effect between cigarette and non-cigarette tobacco products. CONCLUSIONS: There is sufficient evidence in support of the effectiveness of price increases to reduce consumption of non-cigarette tobacco products as it is for cigarettes. Positive substitutability between cigarette and non-cigarette tobacco products suggest that tax and price increases need to be simultaneous and comparable across all tobacco products.

  • Journal article
    Shather Z, Laverty A, Bottle RA, Watt H, Majeed FA, Millett CJ, Vamos EPet al., 2018,

    Sustained socio-economic inequalities in hospital admissions for cardiovascular events among people with diabetes in England

    , The American Journal of Medicine, Vol: 131, Pages: 1340-1348, ISSN: 0002-9343

    ObjectiveThis study aimed to determine changes in absolute and relative socio-economic inequalities in hospital admissions for major cardiovascular events and procedures among people with diabetes in England.MethodsWe identified all patients with diagnosed diabetes aged ≥45 years admitted to hospital in England between 2004-2005 and 2014-2015 for acute myocardial infarction, stroke, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Socio-economic status was measured using Index of Multiple Deprivation. Diabetes-specific admission rates were calculated for each year by deprivation quintile. We assessed temporal changes using negative binomial regression models.ResultsMost admissions for cardiovascular causes occurred among people aged ≥65 years (71%) and men (63.3%), and the number of admissions increased steadily from the least to the most deprived quintile. People with diabetes in the most deprived quintile had 1.94-fold increased risk of acute myocardial infarction (95% CI 1.79-2.10), 1.92-fold risk of stroke (95% CI 1.78-2.07), 1.66-fold risk of CABG (95% CI 1.50-1.74), and 1.76-fold risk of PCI (95% CI 1.64-1.89) compared with the least deprived group. Absolute differences in rates between the least and most deprived quintiles did not significantly change for acute myocardial infarction (P=0.29) and were reduced for stroke, CABG and PCI (by 17.5, 15 and 11.8 per 100,000 people with diabetes, respectively, P≤0.01 for all).ConclusionsSocio-economic inequalities persist in diabetes-related hospital admissions for major cardiovascular events in England. Besides improved risk stratification strategies considering socio-economically defined needs, wide-reaching population-based policy interventions are required to reduce inequalities in diabetes outcomes.

  • Journal article
    Hone TV, Macinko J, Millett C, 2018,

    Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals?

    , Lancet, Vol: 392, Pages: 1461-1472, ISSN: 0140-6736

    The Sustainable Development Goals (SDGs) are now steering the global health and development agendas. Notably, the SDGs contain no mention of Primary Health Care (PHC) – reflecting disappointing implementation of Alma-Alta over the past four decades. The recently-published draft Astana declaration (Alma-Ata 2.0) restates the key principles of PHC and renews these as driving forces for achieving the SDGs, emphasizing Universal Health Coverage (UHC). We use accumulating evidence to demonstrate that countries that reorientate their health systems towards primary care are better placed to achieve the SDGs than those with hospital-focused systems or limited investments in health. We then argue that an even bolder approach which fully embraces the Alma-Ata vision of PHC could deliver substantially greater SDG progress – by addressing the wider determinants of health, promoting equity and social justice throughout society, empowering communities, and as a catalyst for advancing and amplifying UHC and synergies among SDGs.

  • Conference paper
    Chang C, Vamos E, Palladino R, Majeed A, Lee T, Millett Cet al., 2018,

    Impact of the NHS Health Check on inequalities in cardiovascular disease risk: a difference-in-differences matching analysis

    , Publisher: BMJ Publishing Group, Pages: 11-18, ISSN: 0143-005X

    Background We assessed impacts of a large, nationwide cardiovascular disease (CVD) risk assessment and management programme on sociodemographic group inequalities in (1) early identification of hypertension, type 2 diabetes (T2D) and chronic kidney disease (CKD); and (2) management of global CVD risk among high-risk individuals.Methods We obtained retrospective electronic medical records from the Clinical Practice Research Datalink for a randomly selected sample of 138 788 patients aged 40–74 years without known CVD or diabetes, who were registered with 462 practices between 2009 and 2013. We estimated programme impact using a difference-in-differences matching analysis that compared changes in outcome over time between attendees and non-attendees.Results National Health Service Health Check attendance was 21.4% (29 672/138 788). A significantly greater number of hypertension and T2D incident cases were identified in men than women (eg, an additional 4.02%, 95% CI 3.65% to 4.39%, and 2.08%, 1.81% to 2.35% cases of hypertension in men and women, respectively). A significantly greater number of T2D incident cases were identified among attendees living in the most deprived areas, but no differences were found for hypertension and CKD across socioeconomic groups. No major differences in CVD risk management were observed between sociodemographic subgroups (eg, programme impact on 10-year CVD risk score was −1.13%, −1.48% to −0.78% in male and −1.53%, −2.36% to −0.71% in female attendees).Conclusion During 2009–2013, the programme had low attendance and small overall impacts on early identification of disease and risk management. The age, sex and socioeconomic subgroups appeared to have derived similar level of benefits, leaving existing inequalities unchanged. These findings highlight the importance of population-wide interventions to address inequalities in CVD outcomes.

  • Journal article
    Been JV, Mackay DF, Millett C, Soyiri I, van Schayck CP, Pell JP, Sheikh Aet al., 2018,

    Smoke-free legislation and paediatric hospitalisations for acute respiratory tract infections: national quasi-experimental study with unexpected findings and important methodological implications

    , TOBACCO CONTROL, Vol: 27, Pages: E160-E166, ISSN: 0964-4563
  • Journal article
    Blanchet K, El-Zein A, Langer A, Sato M, et al, Rawaf S, et alet al., 2018,

    Support for UNRWA’s survival

    , The Lancet, Vol: 392, Pages: 1009-1010, ISSN: 0140-6736
  • Journal article
    Massuda A, Hone T, Gomes Leles FA, de Castro MC, Atun Ret al., 2018,

    The Brazilian health system at crossroads: progress, crisis and resilience

    , BMJ Global Health, Vol: 3, ISSN: 2059-7908

    The Unified Health System (Sistema Único de Saúde (SUS)) has enabled substantial progress towards Universal Health Coverage (UHC) in Brazil. However, structural weakness, economic and political crises and austerity policies that have capped public expenditure growth are threatening its sustainability and outcomes. This paper analyses the Brazilian health system progress since 2000 and the current and potential effects of the coalescing economic and political crises and the subsequent austerity policies. We use literature review, policy analysis and secondary data from governmental sources in 2000–2017 to examine changes in political and economic context, health financing, health resources and healthcare service coverage in SUS. We find that, despite a favourable context, which enabled expansion of UHC from 2003 to 2014, structural problems persist in SUS, including gaps in organisation and governance, low public funding and suboptimal resource allocation. Consequently, large regional disparities exist in access to healthcare services and health outcomes, with poorer regions and lower socioeconomic population groups disadvantaged the most. These structural problems and disparities will likely worsen with the austerity measures introduced by the current government, and risk reversing the achievements of SUS in improving population health outcomes. The speed at which adverse effects of the current and political crises are manifested in the Brazilian health system underscores the importance of enhancing health system resilience to counteract external shocks (such as economic and political crises) and internal shocks (such as sector-specific austerity policies and rapid ageing leading to rise in disease burden) to protect hard-achieved progress towards UHC.

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